NC0021181_Owner Name Change_20160407

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Donald R.van der Vaart
Governor WATER QUALITY PERMITTING SECTION Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for oisnership changes or name changes of NI'DEli �%aste�%mer permits.
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1. NPDES Permit No.(for which the change is requested): N C 0 0 2 1 1 8 1
or
Certificate of Coverage#: N C G 5
IL Existing Permittee Information:
a. Permit issued to(company name): City of Belmont
b. Person legally responsible for permit: Barry L Webb
First Ml Last
City Manager
Title
PO Box 431
Permit Holder Mailing Address
Belmont NC 28012-
City State Zip
[phone] [phone]
Phone Fax
c. Facility name:
d. Facility's physical address: 298 Parkdale Drive
Address
Belmont NC 28012-
city State Zip
e. Facility contact person: Sandra Craft [phone]
First / MI / Last Phone
Ill. 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): CitN' of Belmont
c. Person legally responsible for permit: Adrian T Miller
First MI Last
Interim City Manager
Title
PO BOX 431
Permit Holder Mailing Address
Belmont NC 28012-
City State Zip
[phone] [e-mail]
Phone E-mail Address
Page I ot'2 Revised 711112014

d. Facility name: Belmont WTP
e. Facility's physical address: 301 North Tenth Street
Address
Belmont NC 28012-
City State Zip
f. Facility contact person: Joseph A Roy
First MI Last
Sr. Plant Operator, ORC
Title
[phone] [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
❑ No(please explain)
If applicable,the applicant shall submit a major permit modification request to DWR. A major 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 02H .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.
PERMIT TF?E CERTIFICATION(Permit holder prior to ownership change):
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 information is not included,this application package will be returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
attest that this application for a name/ownership change has been reviewed and is accurate and complete to the
best of my know edge. I understand that if all required parts of this application are not completed and that if all required
supporting i atio not incluyled,this application package will be returned as incomplete.
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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
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 7;%11/2014