WQ0002571_Application_20240404

State of North Carolina
DWR Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources FORM: NDPONC 06-16
1. EXISTING PERMITTEE INFORMATION: {�f
Jill
1. Permittee's name: �5 ►`d�%
2. Signature authority's name: _ per 15A NCAC 02T .010 b Title: W
3. PctTnittee's mailing address: u
City: s.xCt,l ���_ Stater Zip: M ( t
4. Permittee's contact information: Phone number: (_)_ _ Email Address:
5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120:
Has the Permittee or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ;;KNo
b. Has previously abandoned a wastewater treatment facility without properly closing that facility.) ❑ Yes orXNo
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes orNo
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes orj2'*N o
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)t2)? ❑ Yes oroNo
L=A numP� u5,
11. FACILITY INFORMATION: 11 \ 1 1ty 5 U* �
1. Facility name: CSC I +' V_ V �" e 1l I w
2. Facility's physical address: 2&0 t'- Q( lqui
�' W
City: ate
1 St: ��"1 Zip: w`r_.)— County: Select
Ill. PERMIT INFORMATION: � �
1. Existing permit number. WwSlL and most recent Issuance date:
2. Existing permit type: Select
3. Reason for the permit application: Select
4. Has the facility been constructed? ❑Yes or ❑ No
IV. APPLICANT INFORMATION: J. V_4-,6�0
a
1. Applicant's name: OC30I,\j v n Lo
__g —LITav7s
2. Signature authority's name: Y 4Y1� _� 1 2; �0 per 15A NCAC 02T .010 b Title: l 1
3. Applicant's mailing address a
City: State: 'Lip: 16 A ' -
4. Applicant's contact infaration: Phone number: (%�J �4� S' t�0 Email Address:
rrr-
5. Demonstration ofhistorical consideration for permit approval — 15A NCAC 02T.0120: C
Has the Applicant orany parent, subsidiary or other affiliate exhibited the following?
a Has been convicted of environmental crimes under Federal law or G.S. 143.268? ElYes or f No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes 50 No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes oxrd No
d. Is non -compliant wilh an existing non discharge permit, settlement agreement or order? ❑ Yes o,,ffNo
e. Has unpaid annual fees in accordance with I SA NCAC 02T .0105(e][2]? ❑ Yes or KNO
FORM: NDPONC 06-16 Page I of 2

Existing Permittee's Certifcatlon per 15A NCAC 02T .0106(b):
that this application for
(Signature Authority's name & title from Application Item 1.2.)
(Facility name from Application Item II.I.)
has been reviewed by me and is accurate and complete to the best army knowledge. I understand that prior to rcissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will result in an
enforcement action that may include civll penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the
Division of Water Resources should a condition of the existing permit be violated. 1 also understand that if ail required parts of this
application package are not earn pleted and that if all required supposing information and attachmt,nts are not included, this application
package will be returned as incomplete. I further certify that the existing Permiace or any affiliate has not been convicted of an
environmental crime, has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where
aft appeals have been exhausted or abandoned, are compliant with any active compliance schedule, and do not have any overdue annual
fees per 15A NC C 02T,0! 05[e1.
NOTE — in accordance with General Statutes 14 - 15.6 and 43-2 5 B any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed SI 0,000 as e11 as civil penalties up to $25,000 per violation.
Signature:
Applicant's Certification per 15A NC LC 02T ,0106th1:
;:a❖ti[ that this application for
(Signature Authority's name & title from Application here I % -1 )
(Facility name from Application Item 11.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand than atier rats uar:;c i�: nu „_r
into the Appiicartt's name, any discharge of wastewater from this non discharge system to surface waters or the land µ•ill result to an
enfo=rnem action that may include civil penal(ies, injunctive relief, and/or criminal prosecution. I wit make no cisim againsl the
IDivision of Water Resources should a condition afthis permit be violated. t also understand that ifatl required pans oFthis application
package are not completed and that if all required supporting information and anaehmcros are not included, this application package
will be returned to me as incomplete- I fwthcr certify that the Applicant or any aIfIWe has not been convicted of an environmental
crime, has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where all appeals have
been exhausted or abandoned, are compliant with any active compliance schedule, and do not have any overdue annual fees per)LA
NCAC 02T .0105(e)}.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B. any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed 510,008 as ! as civil penalties up to 525,000 per violation.
Signature: Date:
FORM: NDPONC 06-16 Page 2 of 2