NC0020800_Legally Responsible_20160831

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 NPDES 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 8 0 0
or
Certificate of Coverage #:
NC G5
M Existing Permittee Information:
a. Permit issued to (company name):
Town of Andrews
b. Person legally responsible for permit:
William Green
RECEIVEEDINCDEOIDINR
First MI Last
Town Administrator
AUG 31 2016
Title
P.O. Box 1210
vVacer Qualit
Permit Holder Mailing Address
Permitting Section
- Andrews --NC- - 28901 -
City State Zip
[phone]-
Phone Fax
c. Facility name:
Andrews Wastewater Treatment Plant
d. Facility's physical address:
464 Reagan Ave.
Address
Andrews NC, 28901
City State Zip
e. Facility contact person:
Timothy B. Wood [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: Name change of "Person legally responsible for permit" only. From
William Green to Ed Burchins
b. Permit issued to (company name):
c. Person legally responsible for permit:
Town of Andrews
Ed Burchins
First MI Last
Town Andministrator- -
'Title
P.O. Box 1210 -
Permit Holder Mailing Address
Andrews NC 28901 -
City State Zip
Page 1 of 2 Revised 710111014

townadministrator@andrewsnc. c
[phone] om
Phone E-mail Address
d. Facility name: Andrews Wastewater Treatment Plant
e. Facility's physical address: 464 Reagan Ave.
Address
Andrews NC 28901 -
City State Zip
f. Facility contact person: Timothy B Wood
First MI Last
Operator in Responsible Charge
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. Amajor 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.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 applicationare not completed and that if all required
supporting information is not included, this application package will be returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
I, Ed Bur/aat this application for a name/ownership change has been reviewed and is accurate and complete to
the best ofe. I understand that if all required parts of this applicationare not completed and that if all required
supportings not included, this application package will be returned as incomplet .
Signature Date
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 7/01/2014