NC0028037_Owner Name Change_20160229

ATM
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 2 8 0 3 7
or
Certificate of Coverage#: N C G 5
H. Existing Permittee Information:
a. Permit issued to(company name): City of Lexington
b. Person legally responsible for permit: Roger D Jones
First MI Last
Public Services Manager
RECEIVED/NCpFQ/DwR
Title
FEB 2 711 S. Talbert Boulevard
'U16 Permit Holder Mailing Address
yya Quality Lexington NC 27295-
ittlrlD motion City State Zip
[phone] [phone]
Phone Fax
c. Facility name: Lexington Water Treatment Plants #1 and #2
d. Facility's physical address: 2979 Greensboro Street Extension
Address
Lexington NC 27295-
City State Zip
e. Facility contact person: Ronald S. Walser [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): City of Lexington
c. Person legally responsible for permit: Roger D Jones
First MI Last
Public Services Manager
Title
711 S. Talbert Boulevard
Permit Holder Mailing Address
Lexington NC 27295-
City State Zip
[phone] [e-mail]
Phone E-mail Address
Page 1 of 2
Revised 7/01/2014

d. Facility name: Lexington Water Treatment Plants#1 and#2
e. Facility's physical address: 2979 Greensboro Street Extension
Address
Lexington NC 27295-
City State Zip
f. Facility contact person: Ronald S Walser
First MI Last
Utility Plant Supervisor
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
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
R
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.
t.//2j
2/2 6/201 d
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

LEXINGTON
NORTH CAROLINA
OFFICE OF THE MAYOR
LOCAL FIRST
February 24, 2016
Wastewater Branch RECEIVED/NCDEQ/DWR
Water Quality Permitting Section
Division of Water Resources FEB 2 6 20'-
1617 Mail Service Center Water
Raleigh, NC 27699-1617 Permittj 9 Se Quality
9 Section
Subject: Delegation of Signature Authority
Lexington Water Treatment Plants#1 and #2
NPDES Number NC 0028037
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals
for all permit applications, discharge monitoring reports, and other information relating to the
operations at Lexington Water Treatment Plants#1 and #2 as required by all applicable federal,
state, and local environmental agencies specifically with the requirements for signatory
authority as specified in 15A NCAC 26.0506.
Wes Kimbrell Civil Engineer
If you have any questions regarding this letter, please feel free to contact me at 336.248.3970.
Sincerely,
Newell Clark
Mayor
cc: WSRO, Regional Office, Water Quality Permitting Section
28 West Center Street - Lexington, NC 27292 - 336.248.3910
WWW.LI:XINGTONNC.GOV