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Home My WebLink AboutNC0026921_Owner (Name Change)_20140701 Argr:A 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 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 a(oq a or Certificate of Coverage#: N C G 5 II. Existing Permittee Information: a. Permit issued to(company name): -1-6V-4\ o f Pack 6tn b. Person legally responsible for permit: A ` 1-1 • 0(.1A/it'(tavl First MI Last c Title RECEIVEDIDENR/pWR Po Io k 6 Permit Holder Mailing Address APR — 2 2015 irk A a(237 City State Zip Water Qua( (9(o) dcJ -3 3(9D (r(o) q55;-9SW permitting seCn011 Ppive Fax c. Facility name: Vo k V W AV-no d. Facility's physical address: L3tANeir PIQtA}. Dr. w 1�� t(79,ti- Address1�1 RACOMA w MC— ag3r7( City 11�� State Zip _ e. Facility contact person: ( ;v'kO B Vj , (�it'k-t L (c 10) q" o((D First / MI / Last Phone III. Applicant Information: i a. Request for change is a result of: L!7 Change in ownership of the facility ❑ Name change of the facility or owner If other please explain: b. Permit issued to(company name): Totoin PArk v1/4- c. ,`c. Person legally responsible for permit: A` rtitc,Ott t i lam First MI Last Ukal),C Title Po Y:3ox 55 Permit Holder Mailing Address qACk` City State Zip (9l0) 6W- 3 3 to 0 td000 Fpcadcl'o n @ vphoo. Phone E-mail Address Page 1 of 2 Revised 7/01/1014 d. Facility name: e. Facility's physical address: Address City State Zip f. Facility contact person: First MI Last Title ) Phone E-mail Address IV. Will the permitted facility continue to conduct the same commercial/mdustrial activities conducted prior to this ownership or name change? 0 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, ,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 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 ************************** 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 State of North Carolina DWRDepartment of Environment and Natural Resources Division of Water Resources Division of Water Resources EDMR REGISTRATION FORM Part A. PERMIT/FACILITY INFORMATION 1. NPDES Permit Number: N ICI 0 I 0 I a l 6 1 91 ,21 1 2. Owner/Organization Name: ?row 1 of Parkioh 3. Facility Name: Park1.0., L✓4, TP 4. Facility's Physical Address: Loop foar.I City: PAr k4v4 State: NC Zip Code: -a 3'7 203 '7/ Part B. OWNER USER INFORMATION ii 11 ''nnAA 1 �n� 1. Responsible Official's Name: l 1r V"IG�'1t�1C1 . Title: Y &c (Apr (Owner or duly authorized representative) 2. Mailing Address: `Q(7 3o K City: PaCkCtDIN State: VIC- Zip Code: aq 3 7 3. Telephone Number: C1(O . .6S''3- 33(0O 4. Email Address: +13-04of rkbO&Q 9c41^00 ' CO lig 5. User ID(Assigned by NCDWR eDMR Administrator): Part C. USER ACCOUNT INFORMATION 1. Facility Administrator Permission The Facility Administrator user permission can be assigned at the time of registration by the NCDWR eDMR Administrator. If someone other than the Owner will be responsible for managing facility users within eDMR and you would like the Division to set up the permission at the time of registration,then please provide the user details for the individual who will need the Facility Administrator user permission. Note: If this person will be responsible for submitting eDMR reports, then you will also need to request Submitter permission for this user. In addition to the user details, please specify the permit number(s)to which the user will be associated. If additional space is needed, please make additional copies of the Facility Administrator User Details and complete as needed. Facility Administrator User Details Permit No.(s): (1 W0c9,(99X First Name: Tow yk,..y Middle Name CrCk Last Name: Phone Number: °U )- 4-'74.- ( (o (Cp Email: tt tot,3rrtckPaC141)r1.DCUser ID: (Assigned by DWR eDMR Administrator) NC eDMR Registration Form(Revision 4.0) 1 • 2. Submitter Permission Provide the users,in addition to the Owner,who will need Submitter permission. The Submitter user permission can only be assigned by the NCDWR eDMR Administrator. The Owner specified above will be given full eDMR permissions including Submitter permission. In addition to the user details, please specify the permit(s)to which each user will be associated for eDMR submittal. Should additional space be needed for users and/or permits,please make additional copies of this page and complete as needed. NOTE: The Owner will be responsible for creating all facility users except those with Submitter permissions. In addition to the Owner and Submitter user groups,there are four user types identified by user permission level: Facility Administrator,Certifier, Data Entry and View Only. The Owner and Facility Administrator will have the ability to create and manage facility users. The Facility User Management Guide,located on the eDMR website at http//portal.ncdenr.or9/web/wp/admin/bog/ipu/edmruserdocs,provides the appropriate procedures for facility user management. • 4 Permit No.(s): (CAo 4cia i First Name: 1 E vytokkv ,Middle Name: uAcora *Name: L.,�{-�[� one Number: °(10 " t-74-(p(12 1(D �Etpail }'i+�6&+.5l1oF?orDry .0 Li ;UserID { 9 , (APIIIned by, - MPIOnlstnatod . . Permit No.(s): First Name: Middle Name: ame: • Number: AttL UsrID a ✓�sFM a •.� _ tAsslg»edby��I� �Alminlstrweorj ;.. NC eDMR Registration Form(Revision 4.0) 2 RESPONSIBLE OFFICIAL AUTHORIZATION The Responsible Official,as identified in accordance with Part II,Section B.11 of the Standard Conditions for NPDES Permits and 40 CFR 122.22, is the appropriate individual with the authority to sign applications or reports for the Owner/Organization. I, 4'L h� _s'y\; /(A-A) (printed name), have the authority to make this request for widow sVVAJ— M`1Gt:/I j (Owner/Organization Name). REGISTRATION CERTIFICATION For the permit(s)associated with the Owner identified above, I request permission to submit DMR data using the NCDWR eDMR system. I understand that electronic submittal of the DMR does not fully satisfy US EPA's electronic signature requirements and as a result, I understand I will be required to print,sign,and submit hardcopies(one signed original and a copy) of the eDMR to NCDWR under the same reporting requirements as paper-based DMRs as specified in Part II,Condition D(2)of the NPDES Permit. I agree to protect the security of my user ID and password from compromise and shall take all necessary steps to prevent its loss,disclosure, modification,or unauthorized use. �z ,t1gibe; g4k' 414-Yo/2. Owner/Responsible Official Name(type or print) Official Title(type or print) Thcth ) Owner/Responsible Official Signature Date North Carolina General Statute§143-215.6B provides that: Any person who knowingly makes any false statement,representation,or certification in any application,record,report, plan,or other document filed or required to be maintained under this Article or a rule implementing this Article;or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article;or who falsifies,tampers with,or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article,shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars($10,000). 18 U.S.C.Section 1001 provides a punishment by a fine or imprisonment not more than 5 years,or both,for a similar offense. NC eDMR Registration Form(Revision 4.0) 3