NCG110148_Name-Owner Change Form_4/17/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
NCG110148
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
11. Permit status prior to requested change.
a. Permit issued to: Town of West Jefferson
Company Barre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Brantley Price
Title: Town Manager
Permit holder's mailing address:* Street Address
PO Box 490
Address Line 2
City State / Rovince / Fbgion
West Jefferson North Carolina
Fbstal / Zip Code Country
28694 United States
Phone #:*
33624
63551
c. Facility name:*
d. Facility address:*
Fax #:
Town of West Jefferson WWTP
Street Address
335 Clear Water Dr
Address Line 2
City State / Rovince / Fbegion
West Jefferson North Carolina
Fbstal / Zip Code Country
28694 United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
David Hamilton
Phone #: [phone]

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result r Change in ownership of facility
of: * r Name Change of the facility or owner
b. Permit to be issued to: Town of West Jefferson
Conpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Brantley Price
Title: Town Manager
Permit holder's mailing address:* Street Address
PO Box 490
Address Line 2
aty
State / Province / Fbgion
West Jefferson
NC
Rxstal / Zip Code
Country
28694
United States
Phone #:* Email address:*
33624 admin@t
63551 ownoN.c
om
d. Faciltiy name:* Town of West Jefferson WWTP
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Brandon
Phone #:*
Middle name
3362463558
Email address:* [e-mail]
Last name:*
Patrick

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
f Yes
r No

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this
ownership or name change:*
r Yes
r No

VI. Signature
In the case of an ownership change request, certifications must be signed by both the permit holder
prior to the change and the new applicant. For a name change request, the signed Permittee's
Certification is sufficient.
This completed application is required for both name change and/or ownership change requests.
North Carolina General Statute 143 - 215.6 b (i) 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 [Environmental Management] 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).
Permittee Certification: I attest that this application for a name and/or 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, or if all required supporting information is not included, this application will be considered incomplete.
Permittee Signature
FLrrrit-holder prior to the ownership change, or permt-holder authorizing the narre change
Will another person need to complete or sign this form before it can be submitted? No problem! Simply CLICK
the "Save as Draft" button below and send the URL link to the other party to access the form. Questions? Call Laura
Alexander at [phone] or e-mail her at [e-mail].

Initial Review
Project ID:* NCG110148