NCG551625_Compliance Evaluation Inspection_20240924

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ROY COOPER rr
Governor
MARY PENNY KELLEYt
Secretary '�"p^^"°'�•
RICHARD E.ROGERS,JR. NORTH CAROLINA
Director Environmental Quality
September 24, 2024
Certified Mail 7020 3160 0000 4109 3929
Return Receipt Requested
Sergio Serpas
602 Shiloh Drive
Durham, NC 27703
Subject: Notice of Violation
NOV-2024-PC-0547
Compliance and Evaluation Inspection
Single Family Residence-NPDES Permit NCG551625
Facility: 602 Shiloh Drive
Durham County
Dear Mr. Serpas:
On August 30, 2024, Myles Parker and I from the Raleigh Regional Office of the Division of Water
Resources (DWR) visited your single-family residence(SFR) wastewater treatment system to evaluate
compliance with the subject General NPDES Permit. No one was at home at the time of the inspection.
The inspector left a packet of information regarding Single Family Treatment Systems and the
requirements of the General Permit at the residence.
This wastewater treatment system is located at 602 Shiloh Drive in Durham County and is currently
permitted to Helen Brantley, the previous property owner. Our records indicate the wastewater treatment
system consists of a septic tank, sand filter, tablet chlorinator with chlorine contact chamber, tablet
dechlorinator, and effluent discharge pipe.
General NPDES Permit NCG550000 and Certificate of Coverage(COC)NCG551625 authorize this
discharge of domestic wastewater from your treatment system to receiving waters designated as an
unnamed tributary to Little Lick Creek in the Neuse River Basin. This authorized discharge is in
accordance with the effluent limits and monitoring requirements established within the General Permit.
The subject site visit and file review revealed the following:
NCG550000 Ownership Change Form: According to Durham County deed of records, Sergio
Serpas owns the residence and property located at 602 Shiloh Drive in Durham, North Carolina.
As the property owner, you are also the owner of the existing single-family wastewater treatment
system, which treats the domestic wastewater from the residence and releases the effluent to the
receiving waters indicated above. Because the treatment system makes an outlet to waters of the
state, it is an activity for which the subject permit is required. To comply with North Carolina
General Statute § 143-215.1(a), which requires a person to obtain a permit to make an outlet into
the waters of the state, you will need to complete and submit the attached NCG550000
R E Q�� North Carolina Department of Environmental Quality I Division of Water Resources
,-
Raleigh Regional Office 1 3800 Barrett Drive I Raleigh,North Carolina 27609
a* + w /� 919191.4200

Ownership Change Form to the Division. If you have any questions regarding change in
permit ownership or completing the form, then please contact Myles Parker at 919-791-4236.
Treatment system component failure. The site visit revealed what appeared to be a failed pump or flow
blockage that has resulted in untreated domestic wastewater to the ground surface, such that it has short-
circuited treatment from the sub-surface sand filter and from disinfection and is ponding. See Attachment
B for photos taken during the inspection.
This system failure has been ongoing long enough that the wastewater is ponded, the ground is soft.`
saturated and is evident through untreated waste. Additionally, there were significant amounts of
nutrients and solids (human waste) observed at the outfall pipe. This is a significant vector and pathogen
concern.
Accordingly,these observations constitute violations of the following conditions of your General
NPDES Permit(COC) NCG551625:
Part 1, D.Operations& Maintenance& Records
(2.)Bypassing of Treatment Facilities:Treatment systems shall be maintained at all times to prevent
seepage of sewage.
(4.) System Components: All system components, including but not necessarily limited to, septic
tanks, surface sand filters, other filter components, pumpirecirculation tanks, controls and alarms,
disinfection units, dechlorination apparatus, and the outfalls shall be maintained at all times and in
good operating order. The Permittee is responsible for the operation and maintenance of the entire
wastewater treatment system.
(6.) Outfall Location: A visual review of the outfall location shall be executed twice each year(one
at the time of sampling) to ensure that no visible solids or other obvious evidence of system
malfunctioning is observed. Any visible signs of a malfunctioning system shall be documented, and
steps taken to correct the problem.
Part II. Section B. General Conditions
2. Duty to Mitigate
The permittee shall take all reasonable steps to minimize or prevent any discharges of sludge use
or disposal in violation of this permit with a reasonable likelihood of adversely affecting human
health or the environment [40 CFR 122.41 (d)].
Part II, Section C. Operation and Maintenance of Pollution Controls
2. Proper Operations and Maintenance. The Permittee shall at all times properly operate and
maintain all facilities and systems of treatment and control (and related appurtenances) which are
installed or used by the Permittee to achieve compliance with these conditions of this permit. Proper
operation and maintenance also includes adequate laboratory controls and appropriate quality
assurance procedures. This provision requires the Permittee to install and operated backup or
auxiliary facility only when necessary to achieve compliance with the conditions of the permit [40
CFR 122.41(e)].
North Carolina Department of Environmental Quality I Division of Water Resources
_ Raleigh Regional Office 1 3800 Barrett Drive Raleigh,North Carolina 27609
919,791.4200

These violations and any future violations are subject to civil penalty assessment of up to$25,000 per day
per violation. Please respond to this letter in writing within 30 days of receipt this letter. Your response
should minimally address the following items:
l) Please explain detail in your written response what steps you have taken to correct your
malfunctioning system. (e.g. pumping septic tank, replacement of pump, panel repair,
findings'observations and repairs efforts of plumber, receipts etc.)
2) Discuss in your response how the system has a been repaired, such that wastewater is being
treated and disinfected,as appropriate.
Your wastewater system is failing or is not operating properly. The Raleigh Regional Office requests that
you (Permittee)secure a plumber or a NC certified engineer to inspect your existing system and
determine what repairs are needed and or what components need replacing. This is necessary to ensure
that the system functions as intended and meets the conditions of your permit, including meeting the
effluent monitoring limits.
Finally, Attachment A includes additional findings of the compliance evaluation inspection and
highlights select system operational and maintenance requirements for your reference and future
use.
Thank you for your attention to this matter. This office requires that the violations, as detailed above,
be abated immediately and properly resolved. Environmental damage and/or failures to properly
comply with permit conditions and to properly operate and maintain the waste treatment system, as stated
above, has occurred. Please understand,periodic or routine occurrence of waste discharges in
violation of permit conditions(sewage) must be eliminated. This cannot continue to occur.
These violations and any future violations are subject to a civil penalty assessment of up to a
maximum of$25,000.00 per day for each violation. Your above-mentioned response to this
correspondence will be considered in any civil penalty assessment process that may occur.
If you have questions or comments about the inspection, this report or the requirements to take corrective
action, please contact Myles Parker at [phone] (M ly es.b.parker u,deg.nc.goy) or me at 919-791-
4232 or via email at Vanessa.Manuel(r�deq.tic.�.
Sincerely,
�'r ' F W.,
Vanessa Manuel, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Attaclunent(s): EPA Water Compliance Inspection Report
Attachment A Inspection Findings
Attachment B Inspection Photos
Ownership Change Form
Cc: Laserfiche
ME Q�� North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office 1 3800 Barrett Drive Raleigh,North Carolina 27609
oNaOar') , w'WroWJro�n� /'� 90.791.4200

Attachment A
Inspection Findings NC6551625,602 Shiloh Drive
1. Pumping the septic tank: Septic tanks should be pumped out approximately every five years or
when the solids level is found to be more than 13 of the liquid depth in the septic tank
compartment, whichever is greater. A pumping company can check the status periodically and
detennine when pumping is required.
For your reference, the General NPDES Permit requires the permittee to retain records
associated with sewage disposal activities for a period of at least 5 years.
2. Chlorine tablets in the chlorinator: You are reminded that it is required that chlorine tablets be
maintained in the chlorinator to ensure proper disinfection of the discharged wastewater.
Chlorine tablets are intended to provide effective disinfection and preventrlimit harmful bacteria
from discharging to the environment. The product label for these tablets must indicate the
tablets are approved for wastewater use and not for swimming pools. Part 1, Section D (1) of
General NPDES Permit NCG550000 requires the permittee to inspect the tablet chlorinator
weekly to ensure there is an adequate supply of tablets for continuous and proper operation.
Section D(4) requires the permittee to maintain all system components, including...disinfection
units...at all times and in good operating order. The inspector did not observe any chlorine tablets
in the chlorinator tubes.
Please ensure the correct type of tablets are used and maintained in the chlorinator and de-
chlorination contact tubes as required by the General NPDES Permit. Please be sure to keep
records of this nature available for your reference and used during f dure inspections. (Note:
Examples of these products (disinfection and the disinfection neutralizer) can be readily observed
online. You may wish to conduct an online search by using google for "chlorine tablets for
x,astewater"and "dechlorination tabletsfor wastewater').
3. Dechlorination tablets: You are responsible for always having dechlorination tablets (if a
required part of your system) in place. They must be the kind for wastewater treatment and not
for swimming pools. The inspector did not observe any dechlorination tablets in the treatment
unit. Please ensure the correct type of tablets are used and maintained in the dechlorinator as
required by the General NPDES Permit.
4. Discharge outlet location. The permittee is required to conduct a visual review of the outfall
location at least twice each year(once at the time of sampling)to ensure that no visible solids or
other obvious evidence of system malfunctioning is observed. Any visible signs of a
malfunctioning system shall be documented, and steps taken to correct the problem.
s. Analyzing the effluent: Part 1. C., Effluent Limitations and Monitoring Requirements, within
General Permit NCG550000 requires a pennittee to sample and analyze the effluent (wastewater
discharge) leaving the treatment system. This sampling effort is required to be conducted
annually.
If votr have not already collected the effluent for this year,please collect a representative sample
of the effluent and have it analyzed by a certified commercial laboratory. !f no wastewater flow
is observed from your system,please document that information for your records and use during
the next system inspection.
Note: Certified Laboratory listings(see "Commercial In-state listing') can be found at this
entail address: https://www.deq.iic.gov about divisions/water-resources water-
sciences/chemistry-laborato[ /y_laboratory-certification-branch/certi#ied-laborator -]Y istings
6. You are also reminded to maintain all monitoring data and associated maintenance records. These
materials should be maintained for a minimum of five years and be available for review.
DEQ 1 North Carolina Department of Environmental Quality I Division of Water Resources
_ Raleigh Regional Office 1 3800 Barrett Drive i Raleigh,North Carolina 27609
919,791.4200

Attachment B
602 Shiloh Drive (NCG551625)—Inspection Photos,August 30, 2024
A white discharge outlet pipe next to the street This image shows the chlorinator and
surrounded by thick, overgrown vegetation. Black dechlorinator that are aligned with the discharge
sludge can be seen emitted from the septic system pipe of your septic system in the front of your
on the property. yard.
T
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� F
A`I J
ft
This is an image of what we assume to be part of This is an image showcasing leakage in the septic
the septic tank. It is located in the front yard on system moving across the driveway and into the
the left of the driveway to the edge of the front yard where the discharge pipe is located.
property. There is a drip line present which flows
with the slope of the front yard into the area of the
discharge.
s,
M
1 1
Page 1 of 2

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United States Environmental Protection Agency Form Approved.
EPA Washington,D.C.20460 OMB No.2040-0057
Water Compliance Inspection Report Approval expires 8-31-98
Section A: National Data System Coding(i.e., PCS)
Transaction Code NPDES yr/molday Inspection Type Inspector Fac Type
1 IN I 2 15 I 3 1 NCG551625 Ill 121 24/08/30 117 181 C+ 191 S I 201 I
21111111111111111111111111111111111111111111 r6
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 CIA -----------Reserved------
67 70 U 71 I I 72 I N j 731l I 1I174 71 I I I I I I 180
Section B: Facility Data u
Name and Location of Facility Inspected(For Industrial Users discharging to POTW,also include Entry Time/Date Permit Effective Date
POTW name and NPDES oermit Number) 11:30AM 24/08/30 14/07/02
602 Shiloh Drive
602 Shiloh Dr Exit Time/Date Permit Expiration Dale
Durham NC 27703 11:50AM 24/08/30 18/07/31
Name(s)of Onsite Representative(suTitles(s)/Phone and Fax Number(s) Other Facility Data
Ill
Name,Address of Responsible OfficialtTitle/Phone and Fax Number
Contacted
Helen Brantley,602 Shiloh Dr Durham NC 27703111
No
Section C:Areas Evaluated During Inspection(Check only those areas evaluated)
Permit E Operations R Maintenar 0 Records/Reports Self-Monitoring Progran
Facility Site Review 0 Effluent/Receiving Wate
Section D: Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s)and Signature(s)of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Myles Parker DWR/RRO WO/919-7914200/
Vanessa E Ma ueI DWR/RRO W01919-791-4200/
2z q - 23 -20
Signature of Management 0 A R viewer Agency/Office/Phone and Fax Numbers Date
�ipr�.v>'�(eL ci t'9- g�'y'23 2 • X,
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete.
Page# 1

NPDES yr/mo/day Inspection Type (Cont.) 1
NCG551625 J11 1 24108/30 17 18 ICI
CI
Section D:Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
On August 30, 2024, Myles Parker and I from the Raleigh Regional Office of the Division of Water
Resources (DWR) visited your single-family residence (SFR)wastewater treatment system to
evaluate compliance with the subject General NPDES Permit. No one was at home at the time of the
inspection. The inspector left a packet of information regarding Single Family Treatment Systems
and the requirements of the General Permit at the residence.
This wastewater treatment system is located at 602 Shiloh Drive in Durham County and is currently
permitted to Sergio Sepas. Our records indicate the wastewater treatment system consists of a
septic tank, sand filter, tablet chlorinator with chlorine contact chamber, tablet dechlorinator, and
effluent discharge pipe.
General NPDES Permit NCG550000 and Certificate of Coverage (COC) NCG551625 authorize this
discharge of domestic wastewater from your treatment system to receiving waters designated as an
unnamed tributary to Little Lick Creek in the Neuse River Basin. This authorized discharge is in
accordance with the effluent limits and monitoring requirements established within the General
Permit.
The subject site visit and file review revealed the following:
NCG550000 Ownership Change Form: According to Durham County deed of records, Sergio Serpas
owns the residence and property located at 602 Shiloh Drive in Durham, North Carolina. As the
property owner, you are also the owner of the existing single-family wastewater treatment system,
which treats the domestic wastewater from the residence and releases the effluent to the receiving
waters indicated above. Because the treatment system makes an outlet to waters of the state, it is an
activity for which the subject permit is required. To comply with North Carolina General Statute §
143-215.1(a), which requires a person to obtain a permit to make an outlet into the waters of the
state, you will need to complete and submit the attached NCG550000 Ownership Change Form to the
Division. If you have any questions regarding change in permit ownership or completing the form,
then please contact Myles Parker at 919-791-4236.
Treatment system component failure. The site visit revealed what appeared to be a failed pump or
flow blockage that has resulted in untreated domestic wastewater to surface, such that it has
short-circuited treatment from the sub-surface sand filter and from disinfection and is ponding. See
Attachment B of photos taken during the inspection.
This system failure has been ongoing long enough that the wastewater is ponded, the ground is soft/
saturated and lawnmower traffic is evident through untreated waste. Additionally, there were
obviously significant amounts of nutrients and solids (human waste) as fly larvae were plentiful, active
and feeding off untreated organic matter. This is a significant vector and pathogen concern.
Accordingly, these observations constitute violations of the following conditions of your General
NPDES Permit (COC) NCG551625:
Part 1, D. Operations & Maintenance & Records
(2.) Bypassing of Treatment Facilities: Treatment systems shall be maintained at all times to prevent
seepage of sewage.
(4.) System Components: All system components, including but not necessarily limited to, septic
tanks, surface sand filters, other filter components, pump/recirculation tanks, controls and alarms,
disinfection units, dechlorination apparatus, and the outfalls shall be maintained at all times and in
good operating order. The Permittee is responsible for the operation and maintenance of the entire
wastewater treatment system.
(6.) Outfall Location: A visual review of the outfall location shall be executed twice each year (one at
the time of sampling) to ensure that no visible solids or other obvious evidence of system
malfunctioning is observed. Any visible signs of a malfunctioning system shall be documented, and
steps taken to correct the problem.
Page# 2

Permit: NCG551625 Owner-Facility: 602 Shiloh Drive
Inspection Date: 08/30/2024 Inspection Type: Compliance Evaluation
Part II. Section B. General Conditions
2. Duty to Mitigate
The permittee shall take all reasonable steps to minimize or prevent any discharges of sludge use or
disposal in violation of this permit with a reasonable likelihood of adversely affecting human health or
the environment [40 CFR 122.41 (d)].
Part II, Section C. Operation and Maintenance of Pollution Controls
2. Proper Operations and Maintenance. The Permittee shall at all times properly operate and
maintain all facilities and systems of treatment and control (and related appurtenances)which are
installed or used by the Permittee to achieve compliance with these conditions of this permit. Proper
operation and maintenance also includes adequate laboratory controls and appropriate quality
assurance procedures. This provision requires the Permittee to install and operated backup or
auxiliary facility only when necessary to achieve compliance with the conditions of the permit [40 CFR
122.41(e)].
These violations and any future violations are subject to civil penalty assessment of up to $25,000
per day per violation. Please respond to this letter in writing within 30 days of receipt this letter. Your
response should minimally address the following items:
1) Please explain detail in your written response what steps you have taken to correct your
malfunctioning system. (e.g. pumping septic tank, replacement of pump, panel repair,
findings/observations and repairs efforts of plumber, receipts etc.)
2) Discuss in your response how the system has a been repaired, such that wastewater is being
treated and disinfected, as appropriate.
Your wastewater system is failing or is not operating properly. The Raleigh Regional Office requests
that you (Permittee) secure a plumber or a NC certified engineer to inspect your existing system and
determine what repairs are needed and/or what components need replacing. This is necessary to
ensure that the system functions as intended and meets the conditions of your permit, including
meeting the effluent monitoring limits.
Finally, Attachment A includes additional findings of the compliance evaluation inspection and
highlights select system operational and maintenance requirements for your reference and future
use,
Thank you for your attention to this matter. This office requires that the violations, as detailed above,
be abated immediately and properly resolved. Environmental damage and/or failures to properly
comply with permit conditions and to properly operate and maintain the waste treatment system, as
stated above, has occurred. Please understand, periodic or routine occurrence of waste discharges
in violation of permit conditions (sewage) must be eliminated. This cannot continue to occur.
These violations and any future violations are subject to a civil penalty assessment of up to a
maximum of$25,000.00 per day for each violation. Your above-mentioned response to this
correspondence will be considered in any civil penalty assessment process that may occur.
If you have questions or comments about the inspection, this report or the requirements to take
corrective action, please contact Myles Parker at(919) 791-4236 (Myles.b,[e-mail],gov) or
me at 919-791-4232 or via email at [e-mail].
Page# 3

Permit: NCG551625 Owner-Facility: 602 Shiloh Dr ve
Inspection Date: 08/30/2024 Inspection Type: Compliance Evaluation
Permit Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new ❑ ❑ 0 ❑
application?
Is the facility as described in the permit? ■ ❑ ❑ ❑
# Are there any special conditions for the permit? ❑ ❑ ■ ❑
Is access to the plant site restricted to the general public? ❑ ❑ ■ ❑
Is the inspector granted access to all areas for inspection? 0 ❑ ❑ ❑
Comment:
Record Keeping Yes No NA NE
Are records kept and maintained as required by the permit? ❑ ❑ ❑
Is all required information readily available, complete and current? ❑ ❑ ❑
Are all records maintained for 3 years (lab. reg. required 5 years)? ❑ Cl ❑
Are analytical results consistent with data reported on DMRs? ❑ ❑ 0 ❑
Is the chain-of-custody complete? ❑ ❑ 0 ❑
Dates, times and location of sampling ❑
Name of individual performing the sampling ❑
Results of analysis and calibration ❑
Dates of analysis ❑
Name of person performing analyses ❑
Transported COCs ❑
Are DMRs complete: do they include all permit parameters? ❑ ❑ M ❑
Has the facility submitted its annual compliance report to users and DWQ? ❑ ❑ 0 ❑
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified ❑ ❑ 0 ❑
operator on each shift?
Is the ORC visitation log available and current? ❑ ❑ 0 ❑
Is the ORC certified at grade equal to or higher than the facility classification? ❑ ❑ M ❑
Is the backup operator certified at one grade less or greater than the facility ❑ ❑ 0 ❑
classification?
Is a copy of the current NPDES permit available on site? ❑ ❑ 0 ❑
Facility has copy of previous year's Annual Report on file for review? ❑ ❑ 0 ❑
Comment:
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ❑ ❑ 0 ❑
Page# 4

Permit: NGG551625 Owner-Facility: 602 Shiloh Drive
Inspection Date: 08/30/2024 Inspection Type: Compliance Evaluation
Operations & Maintenance Yes No NA NE
Does the facility analyze process control parameters, for ex: MLSS, IVICRT, Settleable ❑ ❑ 0 ❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment:
Septic Tank Yes No NA NE
(If pumps are used) Is an audible and visual alarm operational? ❑ ❑ ❑
Is septic tank pumped on a schedule? ❑ ❑ ❑
Are pumps or syphons operating properly? ❑ ❑ 0 ❑
Are high and low water alarms operating properly? ❑ ❑ MEI
Comment:
Sand Filters (Low rate) Yes No NA NE
(If pumps are used) Is an audible and visible alarm Present and operational? ❑ ❑ ■ ❑
Is the distribution box level and watertight? ❑ ❑ ■ ❑
Is sand filter free of ponding? ❑ ❑ 0 ❑
Is the sand filter effluent re-circulated at a valid ratio? ❑ ❑ ❑
# Is the sand filter surface free of algae or excessive vegetation? ❑ ❑ 0 ❑
# Is the sand filter effluent re-circulated at a valid ratio? (Approximately 3 to 1} ❑ ❑ ❑
Comment: Sub-surface sand filter.
Disinfection-Tablet Yes No NA NE
Are tablet chlorinators operational? ❑ 0 ❑ ❑
Are the tablets the proper size and type? ❑ 0 ❑ ❑
Number of tubes in use? 2
Is the level of chlorine residual acceptable? ❑ ■ ❑ ❑
Is the contact chamber free of growth, or sludge buildup? ❑ 0 ❑ ❑
Is there chlorine residual prior to de-chlorination? ❑ 0 ❑ ❑
Comment: There were no chlorine tablets observed in the chlorine tubes.
De-chlorination Yes No NA NE
Type of system ? Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)? E—Is ❑ ❑
Is storage appropriate for cylinders? ❑ ❑ 0 ❑
Page# 5

Permit: NCG551625 Owner-Facility: 602 Shiloh Drive
Inspection Date: 08/30/2024 Inspection Type: Comp iance Evaluation
De-chlorination Yes No NA NE
# Is de-chlorination substance stored away from chlorine containers? ❑ ❑ ❑
Comment:
Are the tablets the proper size and type? ❑ 0 ❑ ❑
Are tablet de-chlorinators operational? ❑ 0 ❑ ❑
Number of tubes in use? 2
Comment: There were no de-chlorination tablets observed in the dechlorination tubes.
Effluent Sampling Yes No NA NE
Is composite sampling flow proportional? ❑ ❑ M ❑
Is sample collected below all treatment units? ❑ ❑ ❑
Is proper volume collected? ❑ ❑ ❑
Is the tubing clean? ❑ ❑ 0 ❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 ❑ ❑ ❑
degrees Celsius)?
Is the facility sampling performed as required by the permit (frequency, sampling type ❑ ❑ ❑
representative)?
Comment:
Effluent Pipe Yes No NA NE
Is right of way to the outfall properly maintained? ❑ 0 ❑ ❑
Are the receiving water free of foam other than trace amounts and other debris? ❑ 0 ❑ ❑
If effluent (diffuser pipes are required) are they operating properly? ❑ ❑ 0 ❑
Comment: The outfall pipe was slightly visible and overgrown with vegetation. Possible solids
observed at/near the outfall pipe.
Page# 6

o•-STArr
ROY COOPER
Ft 17ARF:1+1 S.111S1-P
I21C l'IAR1)F_ROG CRS.IR
, ^,r, t.n virnnnron ra!f1ual,l,
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number tier which the cliange is requested
Certificate of-Coverage
N . 0 G[5- SL�� � �2 �5—
I1 Please provide the folloising for the requested change(revised CoC).
a. Request for change is a result of. ❑ Change in ownership of'the residence property
❑ Name cltansye of the facility or o%%ner
IJ other pleave e\plcrur:
b. CoC «ill be Issued to(person's name
or company name, if applicable): _
c. Owner: person legally responsible for
CuC:
F Ina Nil Last
-- ---- -- •rule
feria, Mulder Nlailnig Address
('It\ State !It)
l
]'hone }} t-marl \ddress
d. I-acilily name 0t'applicable). rpQ2 Ski1Ofl Nye,
C. Facility address: W2 Shi{0 rive
� \ddre s
_D—LA am- 27703
LOIN State /ill
f. Facility contact person:
[i f di ffcrent from Owner] F Ir,t M I Last
{ _ )
Phone Ii-mail Address
Ill, Contact person (if different froin the person legally responsible t'or the CoQ
Flr.t Nil Last
— i 'talc
- Matting Address
f State ZIP
( I
Phone F.-mail Addmss
\•fIL(awluu 1)ep.,rirnenl•d 1.lit uonmenlal Quahn 114u+um..I\�aici Re•„ur.c.
'I-'\urih\alnhun 1ne,9 I I'd- 'lei�311(IIIWI I Ralergb
ter,.,/ •IL1'll'•gNPI

Page 2 of 2
I`, Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change:'
❑ Yes
❑ No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required 1'or both facility-name change and,'or facility ownership
change requests.
❑ Legal documentation of the transfer of ownership(such its a property deed, relevant pages of a
contract,or a bill of sale)is required for an ownership change request.
...................................................................................................................
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICATION
I, ,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 inlin-niation is not included, this application package will be
returned as incomplete.
Signature Date
....................................
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DLQ ' DWR/ NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
charlcs.weaverrit deq.nc.gov