NC0055786_Owner Name Change_20160229 (2)

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
I.
II.
PERMIT NAME/O'WNERSHIP CHANGE "RL QUEST
This form is for ownership changes or name changes. of NPDES wastewater permits.
• "Permittee references the existing permit holder
a "A licant"references the entity applying for the, ownership/name change.
NPDES Permit No. (for which the change is requested): N cC 0 0 5 5 7 8 6
or
Certificate of Coverage#: N C G 5
Existing Permittee Information:
a. Permit issued to (company name):
b. Person legally responsible for permit:
RECEIVED/NCDW/DWIZ
FEB 2 9 2016
sa�malar Qfflng uafty
lSecilon
c. Facility name:
City of Lexington
Roger D Jones
First MI Last
Public Services Manager
Title
71.1 S. Talbert Boulevard
Permit Holder Mailing Address
Lexington NC 27295 -
City State Zip
[phone] [phone]
Phone Fax
Lexington Regional Wastewater Treatment Plant
d. Facility's physical address: 500 Glendale Road
Address
Lexington NC 27295 -
City State Zip
e: Facility contact person: Joseph C. Shaffer [phone]
First / MI / Last Phone
III. Applicant Information:
a. Request for change is a result of:
If other please explain:
b. Permit issued to (company name):
c. Person legally responsible for permit:
Change in ownershipof the facility
® Name change of the facility or owner
Page 1 of 2 Revised 7/0112014
City of Lexington
Roger
D
Jones
First
MI
Public Services. Manager
Last
Title
711 S. Talbert Boulevard
Permit Holder Mailing Address
Lexington NC
27295 -
city State
[phone] [e-mail]
Zip
Phone
E-mail Address.
Page 1 of 2 Revised 7/0112014

d. Facility name: Lexington Water Treatment Plants #1 and #2
e. Facility's physical address:
500 Glendale Road
Address
Lexington
NC
27295 -
City
State
Zip
f. Facility contact person; Jospeh
C
Shaffer
First
MI
Last
Utility Plant Supervisor
Title
[phone]
JCShaffer(a,LexingtonNC.gov
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 RETURN]iI)=UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. This completed application is required for both name change, and/&'owriership change requests.
2. Legal documentation of the transfer of ownership (such ai relevant pages of a contract deed, or a bill of sale) is
re uired for an ownership change request. Articles of incorporation; e`not sufficient for an ownership change.
Applicable regulations: 40 CFR 122.41, 40 CFR 122.61 and 15A NCAC 02H.0 114
................................................................................................................
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.
PERMITTEE 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 isnot included, this application package will be returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
I, R , 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
suppo ' g information is included, this application package will be returned as incomplete.
z In & o 1-
Signature Date
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PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-16.17
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 710112014