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Home My WebLink AboutNC0031160_Owner (Name Change)_20141212 ATA NCDENR North Carolina Department of Environment and Natural Resources Division of Water Resources Pat McCrory John E.Skvarla,III Governor WATER QUALITY PERMITTING SECTION Secretary �iii{a a i a,a-st !"" ' _ #�G 1 �� iz��';!�";:��"i�9,t IY��1� Tr t,t 'r l �,lit tllj I i i"r,x •<,,� �i�,�.li,t � , m i,' ;,•{e 1 !'� i�3 ��;�;,�a. p��;; .'�•' � � ,,�i��, a�G ��u �tr�tg �J • ( 1�,1�X11 11 �. ��'�r s��i j A •! Ij i I �i'i, sl°i.I S;:as,l i`±i €�:ut31€� ' 3ft1�3 f€1 niIj {f IJu?i l€F ��c"d! €Ilflili rtf&I?Il!uA kid iau iH:ii31lUI uLtwa r �r:r•:�,�-�+.tF l',:ti; •ii i�j1,.: ;I,illy•„!j{i 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 3 1 1 6 0 or Certificate of Coverage#: N C G 5 II. Existing Permittee Information: a. Permit issued to(company name): NCDENR/NC DIVISION OF PARK AND RECREATION b. Person legally responsible for permit: MATTHEW H WINDSOR First MI Last PARK SUPERINTENDENT Title 1792 PILOT KNOB PARK RD Permit Holder Mailing Address PINNACLE NC 27043- City State Zip (336)325-2355 (336)3252751 Phone Fax c. Facility name: PILOT MTN ST PARK WWTP d. Facility's physical address: SURRY LINE RD Address PINNACLE NC 27043- City State Zip e. Facility contact person: MATTHEW H WINDSOR (336)3252355 First / MI / Last Phone M. Applicant Information: a. Request for change is a result of: 0 Change in ownership of the facility ❑ Name change of the facility or owner If other please explain: OWNER AFFILIATE CHANGE-DELEGATE AUTHORITY TO R&A LABS b. Permit issued to(company name): NC DENR/NC DPR/PILOT MT STATE PARK c. Person legally responsible for permit: MATTHEW H WINDSOR First MI Last PARK SUPERINTENDENT Title 1792 PILOT KNOB PARK RD Permit Holder Mailing Address Page 1 of 2 Revised 7/01/2014 PINNACLE NC 27043- City State Zip PILOT.MOUNTAIN@NCPAR (336)325-2355 KS.GOV Phone E-mail Address d. Facility name: PILOT MTN STATE PARK WWTP e. Facility's physical address: SURRY LINE RD Address PINNACLE NC 27043- City State Zip f. Facility contact person: MATTHEW H WINDSOR First MI Last PARK SUPERINTENDENT Title PILOT.MOUNTAIN@NCPAR (336)325-2355 KS.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 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 reouired 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¢QIp 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,Matt Windsor,attest that : lication for a name/ownership change has been reviewed and is accurate and complete to the best of my know!..: . I understand that if all required parts of this application are not completed and that if all requ' ' ••seting'•.'•rmation is not included,this application package will be returned as incomplete. IAA 12/12/2014 / Signature Date APPLICANT CERTIFICATION I,Matt Windsor,attest that ' :pplication for a name/ownership change has been reviewed and is accurate and complete to the best of my know .ge. I understand that if all required parts of this application are not completed and that if all -• ' -• ; p.• . ormation is not included,this application package will be returned as incomplete. 12/12/2014 / Signature Date NPDES P u' NAME/OWNERSHIP CHANGE REQUEST Page 2 of 2 Revised 7A91/2014 • ************************** 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 PERMITNAMFJOWNERSHIP CHANGE REQUEST Pap 3 oft !dotted 7/01/2014