NCG551617_Owner Name Change_20190110

PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number. NC00 / / / / or NCG5 iI / (c/ ( / 7
1 Facility Name: - lsYf 9 P. 0 tk in , RECEIVED/DENR/DWR
II. NEW OWNER/NAME INFORMATION: BAN 0 2019
1 This request for a name change is a result of: Water Resource-
Permitting Section
V! a. Change in ownership of property/company
b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit): ,k •2/
66
ko5c, AKe41-1 A ,-ks or?(it c X (Al6� , /ass
VU �
3. New owner's or signing official's name and title: h f/--nooL&, 4/k?_n-c
(Person/ legally responsible for permit)
� W"1CJ
(Title)
4 Mailing address' P. O . Box G�/Dd° City. rrin q5
State./r'c;• Zip Code: Z 7370 Phone: (,93(, ) 3g2- q G L
E-mail address. -Fa,CtUry di r,C4- e h )-rnad. eO,yi
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF
THE APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS.
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
Applicant's Certification:
I, Izrtch, A 1 k rL5 , 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 info ation and attachments are not included, this application package will be
returned as incomplete
Signature: �.(, , 1- Date: II
THE COMPLETE APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

United States Environmental Protection Agency Form Approved
E PA Washington,D C 20460 OMB No 2040-0057
Water Compliance Inspection Report Approval expires 8-31-98
Section A National Data System Coding(i e,PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 [ 2 IS I 3 I NCG551617 I11 121 18/11/08 117 18(�( 19 I S I 2011
21I 111 1 1 I I I I II I I I I I I I I I I I I I I I I I I I I I I I II I I I I i r6
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA -Reserved —
67I I 70I I 71 I I 72 731
I 174 751 I I I I I I I8O
Section B Facility Data LJ l
Name and Location of Facility Inspected(For Industrial Users discharging to POTW,also include Entry Time/Date Permit Effective Date
POTW name and NPDES permit Number) 10 30AM 18/11/08 14/03/07
Furniture Illustrators WWTP
6472 NC Hwy 62 Exit Time/Date Permit Expiration Date
Trinity NC 27370 11 OOAM 18/11/08 18/07/31
Name(s)of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s) Other Facility Data
///
Name,Address of Responsible Official/Title/Phone and Fax Number
Contacted
Kenneth P Orr,PO Box 112 Trinity NC 27370//336-431-2789/
No
Section C Areas Evaluated During Inspection(Check only those areas evaluated)
Permit
Section D Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s)and Signature(s)of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Jennifer F Graznak_ WSRO WQ//336-771-5000/.` '
1 I
Signature of Man em n Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete
Page# 1

NPDES yr/mo/day Inspection Type (Cont) 1 .
31
NCG551617 Ill 121 18/11/08 117 18 I
Section D Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
INSPECTION LETTER
On November 8, 2018, Jenny Graznak and Paul DiMatteo of this office conducted a compliance
evaluation inspection on the wastewater discharge system located at the above address. The State
requires the Division of Water Resources to inspect these types of systems at least once every five
years.According to county records, you are the current owner of this property.You were not present
during the inspection, but you contacted Ms. Graznak following her visit
The inspectors determined that the former Furniture Illustrators, Inc. building located at the
abovementioned address recently burned down and is currently vacant.Therefore, the wastewater
discharge system is not being used. It is our understanding that you very recently purchased this
property and plan to connect to City of Trinity sewer service in the future According to county records,
the building and the wastewater discharge system are on separately owned pieces of property.You - -- - -
own the building, but someone else owns the land with the wastewater system and discharge pipe.
Therefore, if you plan to use the wastewater discharge system in the future, you will need to request an
easement In addition, a Name/Ownership Charge Form is attached for you to complete and return.
INSPECTION NOTES
-The building recently burned down The contractor stated fire was due to electrical issue.
-The current owners plan to use the building for storage.
-Contact#Wanda Aikens [phone]
Page# 2

r Ste'
I
NORTH CAROLINA
ROY COOPER Environmental Quality
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
November 13, 2018
Mr. Keith Aikens, Managing Member
Town Center Development Group II LLC
PO Box 780
Trinity, NC 27370
SUBJECT: Compliance Evaluation Inspection
Certificate of Coverage: NCG551617
6472 NC Highway 62, Trinity (formerly Furniture Illustrators, Inc.)
Randolph County •
Dear Mr. Aikens:
On November 8, 2018, Jenny Graznak and Paul DiMatteo of this office conducted a compliance
evaluation inspection on the wastewater discharge system located at the above address. The
State requires the Division of Water Resources to inspect these types of systems at least once
every five years. According to county records, you are the current owner of this property. You
were not present during the inspection, but you contacted Ms. Graznak following her visit.
The inspectors determined that the former Furniture Illustrators, Inc. building located at the
abovementioned address recently burned down and is currently vacant. Therefore, the
wastewater discharge system is not being used. It is our understanding that you very recently
purchased this property and plan to connect to City of Trinity sewer service in the future.According
to county records, the building and the wastewater discharge system are on separately owned
pieces of property. You own the building, but someone else owns the land with the wastewater
system and discharge pipe. Therefore, if you plan to use the wastewater discharge system in the
future, you will need to request an easement. In addition, a Name/Ownership Change Form is
attached for you to complete and return.
Please be aware that violations of your NPDES permit, or the NC statutes and regulations under
which it is promulgated, are subject to fines of up to $25,000 per day, per violation, as set forth
in NC General Statute (NCGS) 143-215.6A, Enforcement Procedures, Civil Penalties. Your
immediate attention is greatly appreciated. If you have any questions regarding the inspection or
this report, please contact Jenny Graznak or me at [phone].
Sincerely,
Sherri V. Knight, P.E.
Regional Supervisor
Water Quality Regional Operations
Division of Water Resources
E
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1450 W.Hanes Mill Road,Suite 300 I Winston-Salem,North Carolina 27105
336-776-9800

Attachments: EPA Water Compliance Inspection Report
Name/Ownership Change Form
cc: Central Files
WSRO
NPDES Unit
•
Page 2 of 2