NCG130033_Name Ownership Change_20180313

State of North Carolina
DWRCC /1 oDV�I � Department of Environmental Quality
� --„`j Division of Water Resources
1 SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
This form is for ownership changes or name changes of a sewer system permit. Please note that "Permittee" references the
existing permit holder, and that "Applicant" references the entity applying for the ownership/name change.
Sewer permits start with a WQ or WQCS apd contain the terms sewer extension or collection system in the subject field. This
form should not be used for permits with NC, NCG, SW or other types of non -sewer permits beginning with WQ.
For more information, visit the Division's Water Quality Permitting's website:
A. Sewer System Permit Ownership/Name Change (FORM: PNOCF 01-16) Application (All Applications):
❑ Submit an original completed and appropriately executed application (PNOCF 01-16).
❑ The Existing Permittee's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T
.0106 c , an alternate person may be designated as the signing official if a delegation letter is provided from a person who
meets the criteria in 15A NCAC 02T ,0106(b).
❑ The Applicant's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T .0106(c), an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria
in 15A NCAC 02T .0106(b). RECEIVED/DENR/DWR
B. Existing Permit (All Applications): MAR 1 3 2�1�
® Submit a copy of the most recently issued permit and certification.
C. Property Ownership Documentation (All Applications): Water ResourCeS
➢ The Applicant shall demonstrate they are the owner of all property containing the sewer system facilities: Permitting Section
❑ Legal documentation of ownership (i.e., GIS, deed, article of incorporation, or contract), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ Approved board minutes
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility):
❑ Per 15A NCAC 02T .0115(a)(1), provide one copy of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demogstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non -discharge system.
E. Operational Agreements (Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to be
sold):
➢ Home/Property Owners' Association]
❑ Per 15A NCAC 02T .0115(c), submit an original properly executed Operational A eement FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit an original proposed or approved Articles of Incorporation, Declarations and By-
laws that contain the language required by the Operational Agreement.
➢ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit an original of the properly executed Operational AgEeement (FORM: DEV).
F. Package Submitted in Duplicate
❑ Submit a copy of all required documegts in Instructions A-E as required
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED IN DUPLICATE
TO:
NCDEQ - DWR
Water Quality Permitting Section
PERCS Unit
By U.S. Postal Servicel BY Courier/Special Delivery:
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1636 SUITE 925
RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
INSTRUCTIONS FOR APPLICATION PNOCF 0 1- 16 Page 1 of I

State of North Carolina
�� Department of Environmental Quality
Division of Water Resources
w ' s IM z SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
I. EXISTING PERMITTEE INFORMATION:
1. Permittee's name: International Paper Recycling
2. Signature authority's name: Carey Parson per 15A NCAC 02T .0 106(b)
3. Signature authority's title: Plant Superintendent
4. Permittee's mailing address: 201 E. 2§1 St.,
City: Charlotte State: North Carolina Zip: 28206-
5. Permittee's contact information: Phone number: [phone] Fax Number
Email Address: [e-mail]
II. APPLICANT INFORMATION:
1. Applicant's name:
2. Signature authority's name:
3. _ Signature authority's title:
4. Applicant's mailing address:
City: State:
5. Applicant's contact information:
per 15A NCAC 02T .0106(b)
6. Representative's name:
7. Representative's title:
8. Representative's contact information
III. PERMIT INFORMATION:
Zip: -
Phone number:
Email Address:
Phone number: (__j _-
Email Address:
Fax Number (_) _-
Fax Number (_)
1. Existing permit number: NCG 130000 and most recent issuance date: June 1. 2013
2. Reason for the permit application: Select If other, attach detailed explanation
3. Has the facility been constructed? [4 Yes or ❑ No
4. Has the facility been certified per 154 NCAC 02T.01 16? ® Yes or ❑ No
FORM: PNOCF 01-16 Page 1 of 2

IV. CERTIFICATIONS:
Existing Permittee's Certification per 15A NCAC 02T .0106(b):
kl C4&'e. NA 7 ---'td attest that this application
(Signature Authority's name & title from Applic tion Item I.2 & 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit
into the Applicant's name, I will continue to be responsible for compliance with the current permit and any discharge of wastewater
from this system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will also make no claim against the Division of Water Resources should a condition of the existing permit
be violated. I also understand that if all required parts of this application are note completed and that if all required supporting
information and attachments are not included, this application will be returned to me as incomplete.
NOTE - In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any applicagon package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties to $25,000 per violation.
Signature: ��- Date:
Applicant's Certification per
1, (—&Ne} W -j
(Signature Authority's name &
M - L
from Application Item II.2&3.)
that this application
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after issuance of the permit into
the Applicant's name, I will be responsible fpr compliance with the issued permit and any discharge of wastewater from this non -
discharge system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition of this permit be violated.
I also understand that if all required parts of t4is application package are not completed and that if all required supporting information
and attachments are not included, this applica4on package will be returned to me as incomplete.
NOTE - In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any applicatjon package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation. 2
Signature: Date:
FORM: PNOCF 0 1- 16 Page 2 of 2

Certificate of Coverage
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT No. NCG130000
CERTIFICATE OF COVERAGE No. NCG130033
STORMWATER
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
Page 1 of 1
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the
Federal Water Pollution Control Act, as amended,
Iqternational Paper Company
is hereby authorized to discharge storinwater from a facility located at
International Paper Co. -Charlotte Recycle Plant
201 E 28th St
Charlotte
Mecklenburg County
to receiving waters designated as Lithe Sugar Creek, class C water(s) in the Catawba River Basin(s) in
accordance with the stormwater pollution management requirements, monitoring and reporting
requirements, and other conditions set forth in Parts I, II, 111 and IV of General Permit No. NCG 130000
as attached.
This certificate of coverage shall becgme effective June 1, 2013.
This Certificate of Coverage shall remain effective for the duration of the General Permit.
Signed this day June 1, 2013.
for Charles Wakiid, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission
http://portal.ncdenr.org/web/wq/wp/su/permit-renewal 5/23/2013