NC0020338_Owner (Name Change)_20150223

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�� FEB 2 3 2015
NCDENR
Water Quality
North Carolina Department of Environment and Natural Resourle€s itting section
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 ownership changes or name changes of NPUES wastewater permits.
• "Permittee"references the existing permit holder
• "Applicant'references the entity applying for the ownership/name change.
I. NPDES Permit No. (for which the change is requested): N C 0 0 2 0 3 3 8
or
Certificate of Coverage#: N C G 5
II. Existing Permittee Information:
a. Permit issued to(company name): Town of Yadkinville
b. Person legally responsible for permit: Christopher Ong
First MI Last
Town Mangaer
Title
213 Van Buren St
Permit Holder Mailing Address
Yadkinville NC 27055
City State Zip
[phone] [phone]
Phone Fax
c. Facility name: Town of Yadkinville WWTP
d. Facility's physical address: 1620 Fred Hinshaw Rd
Address
Yadkinville NC 27055
City State Zip
e. Facility contact person: Grant F. Trivette [phone]
First / MI / Last Phone
III. 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): Town of Yadkinville
c. Person legally responsible for permit: Perry L Williams
First MI Last
Town Manager
Title
213 Van Buren St.
Permit Holder Mailing Address
Yadkinville NC 27055-
City State Zip
[phone] [e-mail]
Phone E-mail Address
Page I oft Revised 7/01/2014

1,
d. Facility name: Town of Yadkinville WWTP
I
e. Facility's physical address: 1620 Fred Hinshaw Rd.
Address
Yadkinville NC 27055-
City State Zip
f. Facility contact person: Grant F Trivette
First MI Last
WWTP ORC
Title
[phone] gtrivette®yadkinville.org
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
0 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
required 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.
PERMITTEE CERTIFICATION(Permit holder prior to ownership change):
I,Christopher Ong,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 s porting information is not included,this application package will be returned as incomplete.
•
..Z./1 -11
I(=e -
Signature Date
APPLICANT CERTIFICATION
I,Perry Williams,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
req ' ed supporting information is not included,this application package will be returned as incomplete.
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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 27699-1617
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 7/01/2014