NC0024872_Owner (Name Change)_20150326

Mar. 25. 2015 10: 10AM No. 6304 P.
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory John E.Skvarte,Ill
Governor WATER QUALITY PERMITTING SECTION Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for ownership changes or name changes of NPDES wastewater permits.
• "Permittee" references the existing permit holder
• "Applicant"references the entity applying for the ownership/Warne change.
h NPDESPermitNo. (for which the change is requested): N C 0 0 2 4 8 7 2
or
Certificate of Coverage#: N C G 5
a Existing Permittee Information:
a. Permit issued to(company name): Davie County Public Utilities
b. Person legally responsible for permit: Beth Dirks
First MI Last
County Manager
RECEIVED
TitleM�R 2 123 South Main Street/Administration Building
6 2015 Permit Holder Mailing Address
CE�'R LAND Mocksville NC 27028-
S70RMWgrER P RMrr City State Zip
tRM1 S TING [phone]
Phone Fax
c. Facility name: Cooleemee WWTP
d. Paeility'sphysical address: NC Hwy 801 S
Address
Cooleemee NC 27014-
City State Zip
e. Facility contact person: Tim Smith [phone]
First /MI/Last Phone
DT. Applicant Information:
a. Request for change is a result of: ❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b. Permit issued to(company name): Davie County Public Utilities
c. Person legally responsible for permit: Johnny Lambert
First Mt Last
Director of Public Utilities
Title
298 E. Depot Street
Permit Holder Mailing Address
Mocksville NC 27028-
City State Zip
[phone] jlambert4daviecountync.gov
Phone R-mail Address

Mar. 25. 2015 10: 10AM No. 6304 P. 2
d. Facility name: Cooleentee WWTP
e. Facility's physical address: NC Hwy 801 S
Address
Cooleemce NC 27014-
City State Zip
f. Facility contact person: Tim _W Smith
First MI Last
ORC
- Title
( 6)2S4-6680 [e-mail]
Phone E-mail Address
IV. Will the permitted facility continue to conduct the same commercial/industrial activities conducted prior to
this ownership or name change?
® Yes
D No(please explain)
If applicable,the applieantsball submit a major permit modification request to DWR.Amajor modification shall be
defined as one that increases the volume,increases the pollutant load,results in a significant relocation of the
discharge point,or results in a change in the characteristics of the waste generated.
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. This completed application is required for both name change and/or ownership change requests.
2. Legal documentation of the transfer of ownership(such as relevant pages of a contract deed,or a bill of sale)is
renuired for an ownership change request. Articles of incorporation are not sufficient for an ownership change
Applicable regulations:40 CFR 122.41.40 CFR 122.61 and 15A NCAC 021.1.0114
The certifications below must be completed and signed by both the permit holder prior to the change(Permittee).and the
new applicant in the case of an ownership change request. For a name change request,the signed Applicant's
Certification is sufficient.
PERMITTER CERTIFICATION(Permit holder prior to ownership change):
1, .attest that this application for a name/ownership change has been reviewed and is accurate and complete to the
best of my knowledge. I understand that if all required parts of this application are not completed and that if all required
supporting information is not included,this application package will be returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
I, attest that this application:For a name/ownership change has been reviewed and is accurate and complete to the
b of my knowledge. I understand that if all required parts of this application are not completed and that if all required
suppo info I. : 'on is not included,this application package will be returned as incomplete.
Signature Date
**************•***********
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617

Mar. 25. 2015 10: 10AM No. 6304 P. 3
•
Date: 3/2y120ir
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh,NC 27699-1617
Subject: Delegation of Signature Authorti
Facility Name: Coo Ie*Mee• Ideir4e. WA4 R 1 ed .S gelArt
NPDES Permit Number: N I C I O l 0 l a I`I 181713 I
To Whom It May Concern:
By notice of this letter,I hereby delegate signatory authority to each of the following individuals for all
permit applications,discharge monitoring reports,and other information relating to the operations at
the subject facility as required by all applicable federal,state,and local environmental agencies
specifically with the requirements for signatoryauthorityas specified in 15A NCAC 2B.0506.
�� Individual#1 Individual#2(;fapplic ble)
Name: / IM SMj4'11 /Mfit;llC. 14614
Title: QRC e9cic-,p O&
Mailing Address: af/F Pahnig- le 041 xp4rkr Rd wrP
Ibl r1 C,ll/G o2' o e AL
Z� Chi M n„s+tk Nc. 41700e
Physical Address:
oftwerdolo
Email Address: ,s :7-`v%[r�dati talkie1 AG,SO t/ rSjoarkrld w4to®yAdil. Ntt
Office Phone: (3i0) a yl4-L G t 2312. 1 (f7 ,3
Mobile Phone: (33/) (177- 5'd 9G 33c.—/77 - .co 3 7
If you have any questions regarding this letter,please feel free to contact me at either the phone
number or email address below.
jaly,
A thoriz ing Official's Signature
nli.,,+a ealdiG Uii1;Je,r
Authorized Suing Official's Name(type orprin) Title
ayt ‘. -1U,ear /hoacej Me, NC / 07008 - -
Mailing Address
`,'Lo►.v i'1 Cchipti Nc .90((
Email Address
336.. 75.3- 4.- CJ:31?S
Office Phone Mobile Phone
cc: a PAU' WgAVElt Regional office,water Quality Permitting Section
(Enter region name)