NC0024333_Tax Certification_20220902

Goulston
Surface Modification Technologies
August 31, 2022
NC Division of Water Resources
Surface Water Protection Section
1617 Mail Service Center
Raleigh, NC 27699-1617
Re: Application for Tax Certification and Exemption Form TC-WQ
Dear Sir/Madam:
Per application instructions, two copies of our Application Form TC-WQ are attached. Please advise if
application and requested attachments fulfill the requirements to obtain a tax certification and
exemption for Goulston Technologies, Inc.
Should you have any questions, please give us a call.
Thank you.
Sincerely, RECEIVED
P 0.2'2022
Lou Ellen Smith NCDEQIDWRINPDES
Payroll—Finance
Cc: Travis Moscuzza/Real Estate Appraiser Specialist—Union County, NC
700 N.Johnson St. I Monroe, NC 28110, USA
P.O. Box 5025 I Monroe, NC 28111-5025,USA
PHONE [phone] I FAX [phone] I www.goulston.com O

_ For DWRr,Use: TCN:
V.,
'j l' *' 1 wr 1 i` f y t :ter z 4 ,F' l iv t t t l
--,1,174 1 e � ,4 4. . � `' This application is to be used only for waste treatment systems and equipment Rev.
� r1, %- .; � i,;: under the authority of the NC Division of Water Resources (DWR) 01/29/2016
DIRECTIONS:Complete and mail signed copies of the application form and all supporting information to both: 1)the County Tax Administrator for the County in which the facility is located(one copy)
AND 2)to the NC Division of Water Resources,Surface Water Protection Section, 1617 Mail Service Center, Raleigh,NC 27699-1617(two copies). Type or print in blue or black ink. A separate
application package is required for each facility where property proposed for tax certification is located.
THIS APPLICATION WILL NOT BE PROCESSED WITHOUT COMPLETE AND ACCURATE INFORMATION. If you have any questions regarding this applic • a °ffice or the
NC Division of Water Resources at 919/807-6300 or their web site at httos://ox.deq.orod.nc.gov/about/divisions/water-resources/water-resources-permits/waste c s water/tax-
certification for more specific contact information.
Please Note: r D 0 2 2O22
a)Tax Certifications will only be processed for facilities under the authority of the DWR and only if the DWR has found that the described property: cJ
1. Has been or will be constructed or installed; WDES
2.Complies with or that plans therefore which have been submitted to the DR indicate that it will comply with the requirements of the Environmental Mana.e es or
3. Is being effectively operated or will,when completed,be required to operate in accordance with the terms and conditions of the permit,certificate of appro • t•i. .I•Mf -e o approval
issued by the DWR; and
4. Has or,when completed,will have as its PRIMARY rather than incidental purpose the reduction of water pollution;
5.Is being used exclusively(100%)for waste treatment.
b)If approved,the Tax Certification issued will incorporate all requested assets at the facility that meet the criteria for Tax Certification by DWR. Therefore this application must include any new assets
for which Tax Certification is being requested,as well as any assets previously receiving Tax Certification from DWR for which Tax Certification is still needed.
A.Applicant(Applicant is the owner of,and taxpayer for,the property described in this application for tax certification.)
Name of Applicant: Name of Facility:
Goulston Technologies,Inc. Goulston Technologies,Inc.
Address of Applicant,if different from facility where property located: Physical Address of Facility where property located(no P.O.Box):
700 N.Johnson Street, Monroe, NC 28110
(address) (city) (zip) (street address) (city)
(ZIP)
Business Relationship of Applicant to facility where property located: owner
County where property located: Union
Name of Contact Person at Facility where property located:
Bruce Robinson
Doe the Applicant hold any NC Division of Water Resources Permits? 704-289-6464
[ XXXXX Yes / 0 No Title: General Manager-Operations Phone Number: _
If yes,please list Copy attached;IUP Number CM-01.POTW NPDES#NC0024333
Permit No(s):
If approved,will this be the first Tax Certification issued for this Facility? If no,attach any previously issued TCS-MV-002
❑ Yes I xxxx['No tax certifications
B.Complete this Section only if the Operator/User of the facility and equipment is different from the Owner of the facility.
Name of Operator/User:
Operator/User Address:
(address) (city) (zip)
Operator/User Contact Name:
Relationship between Operator/User of facility and equipment and applicant:
***ATTACH A PROCESS SCHEMATIC TO YOUR APPLICATION The number of each item for which Tax Certification is being requested must be shown on the schematic*** Application continues on
Next page

DIVISION OF WATER RESOURCES TAX CERTIFICATION & EXEMPTION APPLICATION PAGE 2
Waste Treatment Systems & Equipment: Waste treatment systems&equipment must be used exclusively for the abatement of water pollution Rev.09/01/2013
For DWR UBe Was asset listed in Asset Number, %of time item is Is this asset
For County lose Only ro„ Descriptiony Equipment permit pollutionYear ti Original Historical
of Waste Treatment Systems or E ui ment the (Yes/No) Vehicle Identification How is this equipment used for abatement? used for pollution replacing a prior
Dstpproved Number WIN) abatement Acquisition Cost" asset?
1 Waste water treatment system-two stage distillation system Yes Dstisa5un Removes organic materials hom water prior to d harge to PO1W 100% 1998 500,000 yes
2 Wastewater treatment system-one stage distillation system yes Distillation Removes organic materials horn wastewater prior to discharge to POTW 100% 1993 250000 yet
3 Storage tanks,pumps,control and piping to support the distillation systems yes Tanks,pumps,piping Tanks,pumps,piping are used in connevc0on with the distillation systems 100%1991 to 2009 250000 yea
4
5
6
7
a
10
11
12
13
14
15
Attach additional pages if necessary
•If the asset Is listed In the DWQ permit,the description must be Identical as listed on the current permit. it the asset is not specifically listed in the OWQ permit the applicant must attach detailed Information as to why the asset should qualify for Tao Certification.
••When certifying systems or equipment,DENR is not certifying the cost of the equipment or the year of acquisition.
Facilities: To qualify for tax certification,the building or section of building being applied for,must be used exclusively for water pollution prevention. A sketch of the building,square footage along with
details as to how the building is used for water pollution prevention,is required.
Land: To qualify for tax certification,the land must be used exclusively for water pollution prevention. A schematic diagram of the facility detailing the land being applied for is required. The amount of land
(acreage)is required and how this land is being used to prevent water pollution. For wastewater treatment and irrigation system list separately the acreage used for actual treatment from the acreage required
by the facility's water quality permit for buffers and setbacks.
SIGNATURE:
I hereby certify that the above equipment,facilities and/or land are used for the purpose stated,and that the information presented in this application is accurate. Furthermore, I certify that any portable or
mobile equipment listed on this application will be used exclusively in the state of North Carolina.
Applicant
Signature: +V►�Ohau` �L a.,.\_ Title:EVPaCFO Date: Aug. 2022
•
(print name also)
NOTICE: The penalty for false statement,represen tion or certification Of: couston Technologies,kw.
herein includes imprisonment and/or the assessment of civil penalties. (Name of Applicant Business Entity) TC-WO

7
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Goulston's Wastewater Treatment Bldg
-45 feet x 75 feet
-dedicated to pretreatment of wastewater prior to discharge to Monroe POTW sewer system
- Pretreatment system consists of distillation systems for concentration and removal of organics
from process washwater
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The question below about irrigation and setbacks does not apply to Goulston

, viren4x. i'4,
�'" NORTH CAROLINA DEPARTMENT OF
r ENVIRONMENT AND NATURAL RESOURCES
Kg•* .t::;:: : :, MOORESVILLE REGIONAL OFFICE
a�"
44CDE1
!'" j+.R.. DIVISION OF WATER QUALITY
FN'• �. October 30, 1998
JAMI*R.HUNT.t�'4:"t_:
17
{ ' ' Mr. Mike Newsome
"•tih *M,:: (../Crl
l,
... „ !: Accounting Manager
' ��,-Y i Goulston Technologies, Inc.
,, JR MCDg`y7,1T1rr�,,.
0- t1tETARY " . Post Office 5025
}` Monroe, North Carolina 28111-5025
` fOOLV`'g I Subject : Tax Certification
mv.I.tarttr.gm4
Wastewater Treatment/Abatement
`ig: ,, 5. i Y Facilities
•- '� ' r NMIVi Goulston Technologies, Inc.
fi ig j Union County, NC
r ` r tt P
.. ..':.. Dear Mr. Newsome:
Wes. tz=l•:•!: �r ,,,w:,
�ilWail' Attached are two (2) copies of Tax. Certification No.
,•. TCS-MV-002 covering wastewater treatment facilities (an
° industrial wastewater pretreatment facility approved under
?-[A-4 I: j.,;, :. the City of Monroe Pretreatment Permit No.CM-01) serving
1.•1
F3
_' 'S Goulston Technologies.
• 1. .: '� Technologies mayuse this Certification to
�.4 r ,;•r. Goulston Techn g
,0. ..
s a t ��' - •;::robtain tax benefits in keeping with the appropriate
t , tMA. is
fffff I statutes.
.� .�. lease
If you have any questions regarding this matter, p
........ contact Mr. G. T. Chen or rue at ( /04) 663-1699.
-.tom---
Sincerely,
« .A D. Rex G eason, P. E.
,.,,,,, .0 , ;;rx-•:,.'. Water Quality Regional Supervisor
,ter
fir
- Attachments
> Y.,: ::-;._.. gtc
919 NORTH MAIN STREET,MooRESY1LLE,NORTH CAROLINA 2,8115
„T ,.y,.. ,,,;•ti_,�• •.;,y re(:�. PHONE [phone] FAX [phone]
s e+ 3 F.!.:.'•'x :'"�''"-' ` -t AN EQUAL OPPORTUNITY/AFPIRMATIVE ACTION EMPLOYER-50%RECYCLEb/10%POET-CONSUMER PAPER
MiertrevragNMEM. 1

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH
TAX CFRTIPIrATION
(Franchise/Privilege; Amortization; Property)
In accordance with the provisions of the General Statutes of North
Carolina (G. S. 105-122 (d) , 105-130 . 10, 105-147 (13) , 105-275 (8) ) ,
this is to certify that :
Goulston Technologies
Located at 700 North Johnson Street, Monroe
Union County
HAS BEEN ISSUED
the City of Monroe Industrial Pretreatment Program Permit #CM-01
for the operation of wastewater treatment/abatement facilities
consisting of two skid mounted evaporation units in series . Skid
Unit No-1 consists of a feed tank, feed pump, evaporation tank,
recirculation pump, heat exchangers, steam blower and a condensate
lift station. Skid Unit No. 2 consists of a feed tank, thin film
evaporator, condenser, recirculation pump, a steam blower and
condensate lift station.
The Environmental Management Commission and the Department of
Environment and Natural Resources have found that the treatment
facilities :
a . Have been constructed or installed;
b. Comply with the requirements of the Commission;
c . Are being effectively operated in accordance with the
terms and conditions of the Permit, Certification of
Approval, or other document of approval issued by the
Commission; and
d. Have as their primary rather than incidental purpose the
reduction of water pollution resulting from the discharge
of wastewater.

Page Two
Goulston Technologies
Tax Certification
Issued at Mooresville, North Carolina, this the 30th day of
October, 1998 by the Directive of the North Carolina Environmental
Management Commission and the North Carolina Department of
Environment and Natural Resources.
D. Rex Gleaso , P. E.
• Water ,Quality Regional. Supervisor
Mooresville Regional Office
TCS-MV-002

Goulston
Fife Listing Report
Book=Internal
FYE Month=December
A In Svc P Depr Disposal Acquired
Sys No Ext C Co Asset No Location CI /L Asset Acct No Date T Meth Department Vendor/Mfg Date Value
002454 WASTE WATER RECOVERY PLANT
000 A 002399 WTU M 11011802008 06/30/98 P SLHY RECOVERY $ 118,023.00
002469 WASTE WATER RECOVERY PLANT
000 A 002414 WTU M h011802008 06/30/98 P SLHY RECOVERY 118,023.00
002487 3-BALL VALVES,1-FLOWTEK FULL PORT VALVE
000 A 002431 WTU M 1011802008 12/01/97 P SLHY H.M.CRAIG 1,734.03
002492 AUTOMAX DISTRIBUTED CONTROLS
000 A 002436 WTU M 1011802008 12/03/97 P SLHY RELIANCE E 32,230.94
002494 1-VIKING PUMP
000 A 002438 WTU M 1011802008 12/01/97 P SLHY ROVER EQl 2,594.80
002495 MISC.SUPPLIES
000 A 002439 WTU M 1011802008 12/01/97 P SLHY WESCO DIS 3,066.34
002520 VALVES,CONNECTORS,SEALS
000 A 002464 WTU M 1011802008 02/06/98 P SLHY ACCRO,INC 282.28
002524 AC CONTROLLER,E-MASTER BOX
000 A 002468 WTU M 1011802008 02/01/98 P SLHY RELIANCE E 793.09
002526 1-ARO PUMP WITH STEAM JACKET
000 A 002470 WTU M 1011802008 02/11/98 P SLHY ROVER EOl 2,216.85
002541 MISC.ELECTRICAL SUPPLIES
000 A 002485 WTU M 1011802008 03/03/98 P SLHY RELIANCE E 4,024.45
002545 REFURBISH WASTE WATER TANKS
000 A 002489 WTU M 1011802008 03/13/98 P SLHY TEMCO,INC 1,087.24
002555 WASTE WATER RECOVERY PLANT
000 A 002499 WTU M 1'011802008 06/30/98 P SLHY RECOVERY 59,011.00
002558 MISC.SUPPLIES
000 A 002502 WTU M 1011802008 04/14/98 P SLHY CHARLOTTI 627.00
002565 6-TAPS,20 CABLE
000 A 002509 WTU M 1011802008 04/01/98 P SLHY RELIANCE E 554.81
002567 1.1"GRADE METER,1.1 1/2 GRADE METER
000 A 002511 WTU M 1011802008 04/02/98 P SLHY ROVER Ea 1,986.86
002569 RELOCATE WASTE WATER TANK
000 A 002513 WTU M 1011802008 04/02/98 P SLHY SECRESTN 850.00
002574 2-CONDENSATE UNITS
000 A 002518 WTU M 1011802008 04/01/98 P SLHY WEEKS•WIL 1,084.24
002596 PAINT WASTE TREATMENT MACHINE
000 A 002540 WTU M 1011802008 05/01/98 P SLHY CATAWBA( 850.00
002598 MISC.SUPPLIES
000 A 002542 WTU M 1011802008 05/01/98 P SLHY FERGUSON 1,500.00
002600 INSULATE WASTE WATER TANKS
000 A 002544 WTU M 1011802008 05/01/98 P SLHY GASTONIA I 4,000.00
002602 MISC.SUPPLIES
000 A 002546 WTU M 1011802008 05/01/98 P SLHY HUGHES SL 1,392.71
002604 MISC.SUPPLIES
000 A 002548 WTU M 1011802008 05/01/98 P SLHY MONROE G 428.95
002608 RENTAL OF BOOM LIFT
000 A 002552 WTU M 1011802008 05/01/98 P SLHY PRIME EQU 1,950.40
002611 HAUL MACHINERY TO MONROE&PLACE ON-SITE
000 A 002555 WTU M 1011802008 05/18/98 P SLHY SECREST N 3,225.00
002613 6-FLOW TEK BALL VALVES
000 A 002557 WTU M 1011802008 05/01/98 P SLHY SOUTHEAS' 559.96
002614 MISC.PIPING SUPPLIES
000 A 002559 WTU M 1011802008 05/01/98 P SLHY SOUTHERN 18,788.94
002629 WASTE WATER RECOVERY PLANT
000 A 002573 WTU M 1011802008 06/30/98 P SLHY RECOVERY 59,011,00
002633 5-GESTRA STEAM TRAPS
August 9,2022 at 225 PM Page 1

Goulston
File Listing Report
Book=Internal
FYE Month=December
A In Svc P Depr Disposal Acquired
Sys No Ext C Co Asset No Location CI pI.Asset Acct No Date T Meth Department Vendor/Mfg Date Value
000 A 002577 WTU M )011802008 06/10/98 P SLHY ABERNATH' 1,408.86
002638 PAINT WASTE TREAMENT MACHINE
000 A 002582 WTU M )011802008 06/08/98 P SLHY CATAWBA( 850,00
002639 MISC,SUPPLIES j
000 A 002583 WTU M 1011802008 06/01/98 P SLHY FERGUSON 2,024.28
002646 MISC.SUPPLIES
000 A 002590 WTU M 1011802008 06/01/98 P SLHY MONROE Cr 2,000,00
002651 MISC.PIPING SUPPUES
000 A 002595 WTU M )011802008 06/01/98 P SLHY SOUTHERN 7,565.03
002658 INSULATE SKID,PIPING FOR WASTE TREATMENT
000 A 002602 WTU M 011802008 06/01/98 P SLHY TRI•CITY ME 11,922.90
002681 MISC.SUPPLIES
000 A 002625 WTU M 1011802008 07/01/98 P SLHY HUGHES SL 1,000.00
002686 MISC.PIPING SUPPLIES
000 A 002630 WTU M 1011802008 07/21/98 P SLHY SOUTHERN 2,417.32
002688 INSULATE PIPING
000 A 002632 WTU M 1011802008 07/01/98 P SLHY TRECITYME 6,118.88
002715 1-SMALL IMP PULLER,1-LARGE IMP PULLER
000 A 002659 WTU M 1011802008 08/01/98 P SLHY MECH EQUI 174.83
002720 INSULATE PIPING
000 A 002664 WTU M 1011802008 08/01/98 P SLHY TRI•CITY ME 3,682,63
002735 1-JABSO PUMP,IMPELLER&SEAL
000 A 002679 WTU M 1011802008 09/01/98 P SLHY MECHANIC) 1,568.88
002737 1-ARO PUMP,AIR END KIT
000 A 002681 WTU M 1011802008 09/01/98 P SLHY ROVER EQl 1,328.07
002766 MISC.SUPPUES
000 A 002710 WTU M 1011802008 10/01/98 P SLHY FERGUSON 2,000.00
002826 WASTE WATER RECOVERY PLANT
000 A 002771 WTU M 1011802008 12/31/98 P SLHY RECOVERY 33,000,00
Grand Total $516,958.57
Count=42
Report Assumptions
Report Name File listing
Source Report<Standard Report>
Catwlation Assumptions:
Not applicable to this report
Group/Sorting Crderia
Group=Waste Treatment upgrades
Indude Assets that meet the following conditions:
Locations WTU
Acquisition Dale is between 01/01/1997 and 12/31/1998
Sorted by:System No,Extension
August 9,2022 at 2 25 PM Page 2

City of Monroe WWTP
Municipality Name
hereafter in this permit to as the
Control Authority
PERMIT
Industrial User Pretreatment Permit(IUP)
To Discharge Wastewater Under the
Industrial Pretreatment Program
CM-01 - N/A
IUP Number 40 CFR Category
(if Applicable)
In compliance with the provisions of North Carolina General Statute 143-215.1, any applicable
federal categorical pretreatment regulations, all other lawful standards and regulations promulgated
and adopted by the North Carolina Environmental Management Commission,and the City of Monroe
Sewer Use Ordinance. The following Industry, hereafter referred to by name or as the permittee:
Industry name,permittee:
Goulston Technologies,Inc.
Facility Located at Street Address:
700 North Johnson Street
City
Monroe
State,Zip
North Carolina, 28110
is hereby authorized to discharge wastewater from the facility located at the above listed address into
the sanitary sewer collection system and the wastewater treatment facility of the City of Monroe
listed below:
RIP Control Authority WWTP name:
City of Monroe WWTP
NPDES Number:
NC0024333
WWTP Address:
Post Office Box 69
State,Zip
Monroe,NC 28111-0069
in accordance with effluent limitations, monitoring requirements, and all other conditions set forth
in Parts I, II, and III of this Industrial User Pretreatment Permit(IUP).
Effective date,this permit and the authorization to discharge shall
become effective at midnight on this date:
July 1,2022
Expiration date,this permit and the authorization to discharge shall
expire at midnight on this date:
December 31,2023
Date Director of Water Resources
Page:1
Effective Date:July 1,2022

IUP, Part I
Industrial User (IU) Specific Conditions
IUP, PART I, OUTLINE:
A) IUP Basic Information
B) IUP Modification History
C) Authorization Statement
D) Description of Discharges
E) Schematic and Monitoring Locations
F) Effluent Limits& Monitoring Requirements
G) Definitions and Limit Page(s)notes
A. IUP Basic Information
Receiving POTW name: POTW NPDES#:
City of Monroe Wastewater Treatment Plant NC0024333
IUP Name: IUP Number:
Goulston Technologies,Inc. CM-01
IUP Effective date: Pipe Numbers,list all regulated pipes:
July 1,2022 02
IUP Expiration date: IUP 40 CFR#(if applicable),or N/A:
December 31,2023 N/A
B. IUP History:
Effective Date: Renewal or Modification: Description of modifications.
7/1/95 issued permit
Date Modified
7/1/98 permit renewal
Date Modified
9/21/98 monitoring frequency for metals
reduced,elimination of TTO,Hg,Cr,Ag
monitoring requirement, change
verbiage in SPCC requirement
6/29/01 Permit issued: changed limits for
BOD, TSS,NI-I3-n, Cu; changed
monitoring frequency; dropped Cd,
Ni; changed verbiage in PART I (F)
1), PART II 17), PART II 29).
10/19/01 Permit modification for frequency of
Industry monitoring of flow
7/1/04 Permit issued; added RO to
treatment units; dropped lead;
changed description of discharge;
changed limits for BOD
IUP#=>CM-01
Page:2
Effective Date:July 1,2022

Effective Date: Renewal or Modification: Description of modifications.
May 15,2007 Renewal Permit issued;changed PART I B.
heading; changed detection limit for
Cyanide;changed page 6 F)to G);
changed verbiage in PART I G) 1.,2.,3.;
changed verbiage in PART II 2. a),b),
c); 10., 13., 16.,25.,27.,30.;changed
verbiage in PART III 2.2.,2.3.; added
PART III 4., 5.,6.
May 15,2009 Modification Permit modification;changed PART I D)
description of discharge.
July 1,2010 Renewal Permit renewal;changed monitoring
frequency for flow;changed verbiage
PART I G);changed limit for cyanide
July 1,2013 Renewal Permit issued; changed TSS detection
limit.
July 1,2016 Renewal Permit renewal
July 1,2019 Renewal Permit renewal
July 1 2022 Renewal/Modification Permit renewal;Changed daily flow
limit, changed mass limits for BOD,
TSS,NH3-N,copper and zinc. Modified
treatment units. Removed concrete
testing lab wastewater.
IUP#=>CM-01
Page:2B
Effective Date:July 1,2022

IUP, Part I
Industrial User (IU) Specific Conditions
C) Authorization Statement:
1) The Permittee is hereby authorized to discharge wastewater in accordance with the
effluent limitations, monitoring requirements, and all other conditions set forth in this
Industrial User Pretreatment Permit (IUP) into the sewer collection system and
wastewater treatment facility of the City of Monroe.
2) The Permittee is hereby authorized to continue operation of and discharge wastewater
from the following treatment or pretreatment facilities. These facilities must correspond
to the treatment units listed on both the application and inspection forms.
IU Treatment Units
List all Treatment Units: Descriptions:
Distillation Distillation of wastewater to concentrate solids
Spill protection
Filtration
Reverse Osmosis
pH adjust
10,000-gallon per day Ultra filtration system (to be added during permit cycle)
10,000-gallon per day MBR treatment unit(to be added during permit cycle)
(3) 20,000-gallon flow equalization tanks(to be added during permit cycle)
3) The Permittee is hereby authorized to, if required by the City of Monroe and after
receiving Authorization to Construct(A to C) from the City of Monroe, construct and
operate additional pretreatment units as needed to meet final effluent limitations.
D) Description of IUP Discharge(s):
1. Describe the discharge(s)from all regulated pipes.
Pipe#01,Description of Discharge:
Domestic
Pipe#02,Description of Discharge:
Process wastewater from North and South buildings, Non-Contact Cooling
Water, & Cooling Tower Blowdown,RO reject water,
IUP#=>CM-01
Page:3
Effective Date:July 1,2022

IUP, Part I
Industrial User (IU) Specific Conditions
E.) Schematic and Monitoring Locations:
The facility schematic and description of monitoring location(s) given below must show
enough detail such that someone unfamiliar with the facility could readily find and
identify the monitoring location(s) and connection to the sewer. Include and identify all
regulated pipes. See attachments on Pages 4A and 4B.
IUP#=>CM-01
Page:4
Effective Date:July 1,2022

IUP, Part I, Section F: Receiving POTW name=> City of Monroe IU name=>Goulston
Effluent Limits and Monitoring Requirements Receiving POTW NPDES# _>NC0024333 IUP# _> CM-01
Effective date for these Limits=7/1/23 Pipe#_> 02
The permittee may discharge from this specific pipe Expiration date for these Limits => 12/31/23 40 CFR#=>N/A
number according to these specific dates, effluent if not applicable put N/A
limits,and monitoring requirements. THE LIMITS ON THIS ARE, (Check one below):
LIMITS for ENTIRE permit period=> X
INTERIM Limits for period# 1 =>
INTERIM Limits for period# 2=>
FINAL Limits Page =>
Conventional Concentration Limits Mass-Based Limits Monitoring Frequency Sample Required
Parameters' Daily Monthly Units Daily Monthly Units by Industry by POTW Collection laboratory
Max Avg. Max Avg. Method Detection
(C or G) Limits
Flow .040 MGD MGD Daily* Every Sample Meter
BOD mg/1 85 lbs/day 1/6 Months' 1/6 months C 2.0 mg/1
TSS mg/I 67 lbs/day 1/6 Months 1/6 months C 2.5 mg/1
Temperature Deg. C Deg.C
pH 6 to 11 Std. Units 6 to 11 Std.Units 1/6 Months 1/6 months G
Other Parameters,Please list alphabetically
Ammonia mg/I 6 lbs/day 1/6 months 1/6 months C .5 mg/1
mg/I lbs/day
Copper mg/1 .07 lbs/day 1/6 months 1/6 months C .010 mg/1
Cyanide mg/I .006 lbs/day 1/6 months 1/6 months G .010 mg/1
mg/1 lbs/day
mg/1 lbs/day
Zinc mg/1 .09 lbs/day 1/6 months 1/6 months C .010 mg/I
Parameters and Prohibitions not specified above are regulated and limited by the (See next section,IUP,Part I, Section G.)
City of Monroe Sewer Use Ordinance. for Definitions and Limits Page(s) notes:
2 1/6 months shall be 1 sampling event consisting of one day every 6 months. IUP, PART I,Page: 5
* The flow meter totalizer shall be recorded each day of discharge with the data submitted as required in PART II (2).
Effective Date:July 1,2022

IUP, PART I
Industrial User (IU) Specific Conditions
G) Definitions and Limit Page(s) notes:
In addition to the definitions in the City of Monroe Sewer Use Ordinance the following
definitions and requirements apply:
1. Composite Sample:
a) A composite sample for the monitoring requirements of this IUP, is defined as the
automatic or manual collection of a series of grab samples of constant volume, not
less than 100 ml,collected at equal time intervals during the entire discharge period
on the sampling day. The time interval between grab samples shall be no greater
than once per hour,or
b) a single,continuous sample collected over a 24 hour period proportional to the rate
of flow. Sampling day shall be a typical production,and discharge day.
2. Daily Monitoring Frequency
Daily Monitoring Frequency as specified in this IUP shall mean each day of discharge.
3. Grab Sample
Grab sample for the monitoring requirements of this IUP,is defined as a single"dip and take"
sample collected at a representative point in the discharge stream over a period of time not
exceeding 15 minutes. The grab sample can be taken manually. Grab samples must be
representative of the discharge.
4. Instantaneous measurement
An Instantaneous measurement for the monitoring requirements of this IUP is defined as a
single reading,observation,or measurement.
IUP#=>CM-01
Page: 6
Effective Date:July 1,2022

PART II
General Conditions
Industrial User Pretreatment Permit (IUP)
Outline of PART II,
1. Representative Sampling 16. Federal and/or State Laws
2. Reporting 17. Penalties
3. Test Procedures 18. Need to Halt or Reduce
4. Additional Monitoring by Permittee 19. Transferability
5. Duty to comply 20. Property Rights
6. Duty to Mitigate 21. Severability
7. Facilities Operation,Bypass 22. Modification,Revocation,Termination
8. Removed substances 23. Reapplication
9. Upset Conditions 24. Dilution Prohibition
10. Right of Entry 25. Reports of Changed Conditions
11.Availability of Records 26. Construction of Pretreatment Facilities
12. Duty to Provide Information 27. Reopener
13. Signatory Requirements 28. Categorical Reopener
14. Toxic Pollutants 29. General Prohibitive Standards
15. Civil and Criminal Liability 30. Reports of Potential Problems
1. Representative Sampling
Samples and measurements taken as required herein shall be representative of the volume and
nature of the monitored discharge. All samples shall be taken at the monitoring points
specified in this permit and,unless otherwise specified,before the effluent joins or is diluted by
any other wastestream, body of water, or substance. Monitoring points shall not be changed
without notification to, and approval by,the permit issuing authority.
2. Reporting
a) Monitoring results obtained by the permittee shall be reported on forms specified
by the City of Monroe, postmarked no later than the twentieth day of the month
following the month in which the samples were taken. Results based on laboratory
analysis shall include the laboratory report. If no discharge occurs during a reporting
period (herein defined as each calendar month) in which a sampling event was to have
occurred, a form with the phrase "no discharge" shall be submitted under the
signatory requirements of Part II, Section 13. Copies of these and all other reports
required herein shall be submitted to the City of Monroe to the following address:
Pretreatment Coordinator
City of Monroe
PO Box 69
Monroe,NC 28111
b) If the sampling performed by the permittee indicates a violation,the permittee shall
notify the City of Monroe within 24 hours of becoming aware of the violation. The
permittee shall also repeat the sampling and analysis and submit the results of the
repeat analysis to the City of Monroe within 30 days after becoming aware of the
violation.
IUP#=> CM-01
Page: 7
Effective Date:July 1,2022

PART II
General Conditions
Industrial User Pretreatment Permit (IUP)
c) Laboratory reports shall include the following:
1. sample preparation -type and date(s) and time(s) performed;
2. analysis start dates and times;
3. analyst(s) initials;
4. analytical techniques and methods used;
5. results of the analyses;
6. chain of custody records which contain the following Information
a. sampling location;
b. date(s)/time(s)sample(s) taken;
c. sample type: composite(time, flow or hand)or grab
d. container type;
e. teflon liner and/or zero headspace,if applicable;
f. type of preservative used, if any;
g. sample iced upon receipt;
h. parameters to be run from that particular bottle;
i. individual(s)who performed the sampling and/or field measurements;
j. samples relinquished/received by who and when (date & time).
In addition,the laboratory performing the analysis shall maintain on file for up to three
years after the analysis all laboratory data taken and calculations during the analysis,
including dates and times, the analyst performing the work, and the data and
calculations from all quality assurance procedures and testing. This data shall be
available for inspection by personnel of the City of Monroe upon request.
3. Test Procedures
Test procedures for the analysis of pollutants shall be performed by a North Carolina Certified
Wastewater Lab in accordance with the techniques prescribed in 40 CFR part 136 and
amendments thereto unless specified otherwise in the monitoring conditions of this permit. The
laboratory shall be certified by the State of North Carolina for each specific test parameter on
which their results are reported.
4. Additional Monitoring by Permittee
If the permittee monitors any pollutant at the location(s) designated herein more frequently
than required by this permit,using approved analytical methods as specified above,the results
of such monitoring shall be submitted to the City of Monroe. The City of Monroe may require
more frequent monitoring or the monitoring of other pollutants not required in this permit by
written notification.
5. Duty to Comply
The permittee must comply with all conditions of this permit. Any permit noncompliance
constitutes a violation of the City of Monroe Sewer Use Ordinance and is grounds for possible
enforcement action; for Permit termination, revocation, and reissuance, or modification; or
denial of a Permit renewal application.
IUP#=>CM-01
Page: 8
Effective Date:July 1,2022

PART II
General Conditions
Industrial User Pretreatment Permit (IUP)
6. Duty to Mitigate- Prevention of Adverse Impact
The permittee shall take all reasonable steps to minimize or prevent any discharge in violation
of this permit which has a reasonable likelihood of adversely affecting human health, the
POTW,the waters receiving the POTW's discharge,or the environment.
7. Facilities Operation,Bypass
The permittee shall at all times maintain in good working order and operate as efficiently as
possible, all control facilities or systems installed or used by the permittee to achieve
compliance with the terms and conditions of this permit. Bypass of treatment facilities is
prohibited except when approved in advance by the City of Monroe. Bypass approval shall be
given only when such bypass is in compliance with 40 CFR 403.17.Treatment facilities shall be
as diagrammed in Figure 2.
8. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the course of treatment or
control of wastewaters shall be disposed of in a manner such as to prevent any pollutants from
such materials from entering the City of Monroe sewer system or the surface waters of the
State of North Carolina. The permittee is responsible for assuring its compliance with any
requirements regarding the generation, treatment, storage, and/or disposal of "Hazardous
Waste" as defined under the Federal Resource Conservation and Recovery Act. The permittee
shall maintain records of disposal of these substances for a minimum of three years.
9. Upset Conditions
An "upset" means an exceptional incident in which there is an unintentional and temporary
noncompliance with the effluent limitations of this permit because of factors beyond the
reasonable control of the permittee. An upset does not include noncompliance to the extent
caused by operational error, improperly designed or inadequate treatment facilities, lack of
preventative maintenance, or careless or improper operations.
An upset may constitute an affirmative defense for action brought for the noncompliance. The
permittee has the burden of proof to provide evidence and demonstrate that none of the factors
specifically listed above were responsible for the noncompliance. Such evidence shall include
operating logs properly signed,or other relevant evidence that:
1. An upset occurred and that the permittee can identify the cause(s) of the upset;
2. The permittee facility was at the time being properly operated; and
3. the permittee submitted notice of the upset as required in Part II, Section 30, of
this permit
4. The permittee complied with any remedial measures required under Part II,
Section 5, of this permit
IUP#=>CM-01
Page: 9
Effective Date:July 1,2022

PART II
General Conditions
Industrial User Pretreatment Permit (IUP)
10. Right of Entry
The permittee shall allow the staff of the State of North Carolina Department of Environment
and Natural Resources, Division of Water Quality, the Regional Administrator of the
Environmental Protection Agency,the City of Monroe,and/or their authorized representative,
upon the presentation of credentials:
1. To enter upon the permittee's premises where a real or potential discharge is located
or in which records are required to be kept under the terms and conditions of this
permit; and
2. At reasonable times to have access to and copy records required to be kept under
the terms and conditions of this permit; to inspect any monitoring equipment or
monitoring method required in this permit; and to sample any discharge of pollutants.
11. Availability of Records and Reports
The permittee shall retain records of all monitoring information, including all calibration and
maintenance records as well as copies of reports and information used to complete the
application for this permit for at least three years. All records that pertain to matters that are
subject to any type of enforcement action shall be retained and preserved by the permittee until
all enforcement activities have concluded and all periods of limitation with respect to any and
all appeals have expired.
Except for data determined to be confidential under the Sewer Use Ordinance, all reports
prepared in accordance with terms of this permit shall be available for public inspection at the
City of Monroe. As required by the Sewer Use Ordinance,effluent data shall not be considered
confidential.
12. Duty to Provide Information
The permittee shall furnish to the Director of Water Resources or his/her designees,within a
reasonable time,any information which the Director,his/her designee,or the Division of Water
Quality may request to determine compliance with this permit. The permittee shall also
furnish, upon request, copies of records required to be kept by this permit.
13. Signatory Requirements
All reports or information submitted pursuant to the requirements of this permit must be
accompanied by the following certification by the Authorized Representative:
"I certify under penalty of law that this document and all attachments were prepared under
my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information submitted. Based on my inquiry of
the person or persons who manage the system,or those persons directly responsible for
IUP#=> CM-01
Page:10
Effective Date:July 1,2022

PART II
General Conditions
Industrial User Pretreatment Permit (IUP)
gathering the information,the information submitted is,to the best of my knowledge and belief,
true, accurate, and complete. I am aware that there are significant penalties for submitting
false information,including the possibility of fine or imprisonment for knowing violations. "
The Authorized Representative shall be as defined by the City of Monroe Sewer Use
Ordinance.If the designation of an Authorized Representative is no longer accurate because a
different individual or position has responsibility for the overall operation of the facility, or
overall responsibility for environmental matters for the company, a new authorization
satisfying the requirements of this section must be submitted to the City of Monroe Water
Resources Director or his/her designee prior to or together with any reports to be signed by an
authorized representative.
14. Toxic Pollutants
If a toxic effluent standard or prohibition (including any schedule of compliance specified in
such effluent standard or prohibition)is established under Section 307(a) of the Federal Clean
Water Act for a toxic pollutant which is present in the discharge and such standard or
prohibition is more stringent than any limitation for such pollutant in this permit,this permit
may be revised or modified in accordance with the toxic effluent standard or prohibition and
the permittee so notified.
15. Civil and Criminal Liability
Nothing in this permit shall be construed to relieve the permittee from civil or criminal
penalties for noncompliance.
16. Federal and/or State Laws
Nothing in this permit shall be construed to preclude the institution of any legal action or
relieve the permittee from any responsibilities,liabilities, or penalties established pursuant to
any applicable Federal and/or State law or regulation.
17. Penalties
The Sewer Use Ordinance of the City of Monroe provides that any person who violates a permit
condition is subject to a civil penalty not to exceed $25,000 dollars per day of such violation.
Under state law,(NCGS 143-215.6B),under certain circumstances it is a crime to violate terms,
conditions,or requirements of pretreatment permits. It is a crime to knowingly make any false
statement, representation, or certification in any record or other document submitted or
required to be maintained under this permit, including monitoring reports or reports of
compliance or noncompliance. These crimes are enforced at the prosecutorial discretion of the
local District Attorney.
IUP#=> CM-01
Page:l l
Effective Date:July 1,2022

PART II
General Conditions
Industrial User Pretreatment Permit (IUP)
The City of Monroe enforcement response will be in accordance with an Enforcement
Response Plan approved by the North Carolina Division of Water Quality and on file in the
office of the Pretreatment Coordinator
18. Need to Halt or Reduce not a Defense
It shall not be a defense for a permittee in an enforcement action that it would have been
necessary to halt or reduce the permitted activity to maintain compliance with the conditions
of the permit.
19. Transferability
This permit shall not be reassigned or transferred or sold to a new owner, new user, different
premises,or a new or changed operation without approval of the City.
20. Property Rights
This permit does not convey any property rights in either real or personal property, or any
exclusive privileges, nor does it authorize any injury to private property or any invasion of
personal rights, nor any infringement of Federal, State or local laws or regulations.
21. Severability
The provisions of this permit are severable and, if any provision of this permit or the
application of any provision of this permit to any circumstance is held invalid, the application
of such provision to other circumstances and the remainder of this permit shall not be affected
thereby.
22. Permit Modification,Revocation,Termination
This permit may be modified, revoked and reissued or terminated with cause in accordance
with the requirements of the City of Monroe Sewer Use Ordinance and North Carolina General
Statute or implementing regulations.
23. Re-Application for Permit Renewal
The permittee is responsible for filing an application for reissuance of this permit at least 120
days prior to its expiration date. The permittee is not authorized to discharge after the
expiration date of this permit if this re-application deadline has not been met.
24. Dilution Prohibition
The permittee shall not increase the use of potable or process water or in any other way attempt
to dilute the discharge as a partial or complete substitute for adequate treatment to achieve
compliance with the limitations contained in this permit.
IUP#=> CM-01
Page:12
Effective Date:July 1,2022

PART II
General Conditions
Industrial User Pretreatment Permit (IUP)
25. Reports of Changed Conditions
The permittee shall give notice to the City of Monroe of any planned significant changes to the
permittee's operations or system which might alter the nature, quality, or volume of its
wastewater at least 60 days before the change. Such changes, however, do not stay any
condition of this permit. If the changes require additions or modifications to pretreatment
facilities to comply with this permit, all such modifications shall be approved and constructed
before planned changes are made. The permittee shall not begin the changes until receiving
written approval from the City of Monroe.Also see PART II,30 below for additional reporting
requirements for spill/slug issues.
26. Construction
No construction of pretreatment facilities or additions thereto shall be begun until Final Plans
and Specifications have been submitted to the City of Monroe and written approval and an
Authorization to Construct has been issued.
27. Reopener
The permit shall be modified or, alternatively, revoked and reissued to comply with any
applicable effluent standard or limitation for the control for any pollutant shown to contribute
to toxicity of the WWTP effluent or any pollutant that is otherwise limited by the POTW
discharge permit. The permit as modified or reissued under this paragraph may also contain
any other requirements of State or Federal pretreatment regulations then applicable.
28. Categorical Reopener
This permit shall be modified, or alternatively, revoked and reissued, to comply with any
applicable effluent standard or limitation issued or approved under Sections 302(b)(2)(C) and
(D), 304(b)(2), and 307(a)(2) of the Clean Water Act, if the effluent standard or limitation so
issued or approved:
1) contains different conditions or is otherwise more stringent than any effluent
limitation in this permit; or
2) controls any pollutant not limited in this permit.
The permit as modified or reissued under this paragraph shall also contain any other
requirements of the Act then applicable.
29. General Prohibitive Standards
The permittee shall comply with the general prohibitive discharge standards in 40 CFR
403.5(a)and (b)of the Federal pretreatment regulations,and shall comply with the prohibitive
discharge standards in §52.020 and §52.023 of the City Sewer Use Ordinance except as
specifically stated otherwise in this permit.
IUP#=>CM-01
Page:13
Effective Date:July 1,2022

PART II
General Conditions
Industrial User Pretreatment Permit (IUP)
30. Reports of Potential Problems
The permittee shall provide protection from accidential and slug discharges of prohibited
materials and other substances regulated by this permit. The permittee shall also notify the
City of Monroe immediately of any changes at its facility affecting the potential for spills and
other accidential discharge,discharge of a non-routine,episodic nature,a non-customary batch
discharge,or a slug load as defined in the City of Monroe Sewer Use Ordinance.
Additionally, the permittee shall notify by telephone the City of Monroe immediately of all
discharges that could cause problems to the POTW including any slug loadings as defined in
the Sewer Use Ordinance. If the permittee experiences such a discharge,they shall inform the
City of Monroe Pretreatment Coordinator,telephone number(704)282-4632,if no answer,the
Wastewater Treatment Plant, telephone number 1704) 282-4630 and [phone], if no
anwer, the Wastewater Treatment Plant Superintendent, telephone number [phone]
immediately upon the first awareness of the commencement of the discharge. Leaving a
message will not be acceptable until all phone numbers listed above have been attempted.
Notification shall include location of the discharge,type of waste,concentration and volume if
known and corrective actions taken by the permittee.A written follow-up report thereof shall
be filed by the permittee within (5) days, unless waived by the City of Monroe.
IUP#i=>CM-01
Page:14
Effective Date:July 1,2022

PART III
Special Conditions
Industrial User Pretreatment Permit (IUP)
1. Slug/Spill Control Plan
The permittee shall provide protection from accidental and slug discharges of prohibited
materials and other substances regulated by this permit. The permittee shall develop and
update,as required,a written slug/spill plan including procedures for preventing a slug or spill
which could cause a violation of the discharge standards of this permit. Any revison of this
plan shall be submitted to the City of Monroe no more than 60 days after the change(s) are
made. If no changes are made to the spill plan, a written statement to that effect must be
submitted to the City of Monroe on or before January 31, throughout the duration of the
permit. The plan shall include the following at a minimum:
1) identification of all chemicals, by name,quantity,and storage location which would
cause a violation of this permit in the event of a spill and the means at each location to
prevent the spill from entering the City sewer system or surface waters of the State of
North Carolina.
2) who has the authority to halt production and/or wastewater discharge in the event
of a spill or upset condition (include phone numbers)
3) who is responsible for implementation and updating of the plan
4) the personnel that should be familiar with the plan
5) the person(s) responsible for notifying the City of Monroe immediately upon
discovery of a problem affecting the characteristics of the wastewater
2. Flow Measurement
1. The Permittee shall provide and operate monitoring facilities for the inspection,
sampling and flow measurement of the permittee's process wastewater discharges.
2. The permittee shall maintain appropriate discharge flow measurement devices and
methods consistent with approved engineering and scientific practices to ensure the
accuracy and reliability of measurements of the volume of monitored discharges.
Devices installed shall be a continuous recording flow meter capable of measuring flows
with a maximum deviation of less than 5% from true discharge rates throughout the
range of expected discharge volumes.
3. The approved wastewater meter shall be installed, maintained, and calibrated once
every six months.
4. The wastewater meter must have a non-resettable mechanical totalizer that reads in
gallons.
IUP#=>CM-01
Page:15
Effective Date:July 1,2022

PART III
Special Conditions
Industrial User Pretreatment Permit (IUP)
5. Flow monitoring equipment and sampling point should be located in an area
accessible to the City of Monroe personnel without prior notification. The City of
Monroe must be supplied with any keys and/or other tools necessary to perform the
aforementioned.
6. There shall be no by-pass capability of the wastewater metering devices or the
sampling point.
7. The permittee shall maintain flow, maintenance, and calibration records for a
minimum of three years.
8. In the event of temporary unintentional failure of the flow meter,the permittee shall
notify the Pretreatment Coordinator as soon as possible,but in no case beyond 24 hours
after first becoming aware of the failure. Repair shall be under taken as quickly as
possible.
3. High Strength Surcharges
Notwithstanding any concentrations permitted for total suspended solids, 5 day BOD or
nitrogen ammonia stated in Part I, Section F of the Permit, the permittee shall be responsible
for the payment of high strength surcharges at rates that may be established in the future by
the Monroe City Council.
4. Special Reopener
The City of Monroe reserves the right to reopen and modify/change limits and or sampling
frequency as deemed necessary.
5. Sludge Management Plan
Within sixty days of the effective date of this Industrial User Permit,the permittee shall submit
a sludge management plan to the City of Monroe.
6. Certified Operator
Pursuant to Chapter 90A-44 of North Carolina General Statutes,and upon classification of
the facility by the Certification Commission,the permittee shall employ a certified
wastewater pretreatment plant operator in responsible charge(ORC) of the wastewater
treatment facilities. Such operator must hold a certification of the type and grade equivalent
to,or greater than the classification assigned to the wastewater treatment facilities by the
Certification Commission. The permittee must also employ a certified backup operator of
the appropriate type and grade to comply with the conditions of Title 15A, Chapter 8A .0202.
The ORC of the facility must visit the wastewater facility as required; must properly manage
and document daily operation and maintenance of the facility; and must comply with all
other conditions of Title 15A,Chapter 8A .0202. The permittee shall submit a letter
designating the operator in responsible charge to the Certification Commission or their
designee within thirty days after facility classification.
IUP#=> CM-01
Page:16
Effective Date:July 1,2022

PART III
Special Conditions
Industrial User Pretreatment Permit (IUP)
7. Action Plan and Schedule
An 18 month permit will be issued,effective July 1,2022 to December 31,2023,subject to the
following time line and conditions:
5-6-22-Draft permit distributed for comments. This will contain your requested limits of
40,000 GPD flow and 85 pounds of BOD, plus other appropriate parameter limits and
conditions.
5-20-22 Permit submitted to NCDEQ for review.
7-1-22-Permit issued to Goulston to be effective 7-1-22 to 12-31-23. This 18 month initial
permit period will allow completion of the pretreatment upgrades,evaluations of actual flow
needs, pretreatment system performance,and balance of hydraulic to pollutant strength
capacity.
7-1-22—Detailed construction drawings submitted to the City for the basis of the
"Authorization to Construct" of the expanded pre-treatment system or sooner at the
discretion of the Permittee.
7-15-22—Comments returned to Goulston related to A to C drawings.
8-1-22—Goulston to submit updated A to C application with all supporting drawings and
figures,followed by issuance of A to C shortly thereafter.
4-15-23 (or sooner at the discretion of the Permittee)-New pre-treatment system on-line.
4-15-23 to 9-1-23—Evaluation of actual flow needs, pretreatment system performance,and
balance of hydraulic to pollutant strength capacity.
9-1-23 -Goulston to submit permit renewal application considering operating data and
timing of phase 2 expansion.
11-15-23-Permit renewal submitted to NCDEQ
1-1-24 New permit issued
IUP#=>CM-01
Page:17
Effective Date:July 1,2022

Form AV-10 •
(Rev.03-14) APPLICATION for TAX YEAR c .O as FINAL NOTICE
Property Tax Exemption or Exclusion COUNTY: UNION APPLICATION DUE BACK: a9 20aa—
Full Name of Owner(s): Grouk.15-kO IIJ -CON NOS 04 CS 1JC
Trade Name of Business: .3
Mailing Address of Owner:
Phone Numbers: Home: Work: Cell:
List the Property Identification Numbers and addresses/locations for the properties included in this application (attach list if needed):
Property ID#: OSa. l0 035 b0 Address/Location:
Property ID#: Address/Location:
Property ID#: Address/Location:
Non-Deferment Exemptions and Exclusions—Check or write in the exemption or exclusion for which this application is made.
These exemptions or exclusions do not result in the creation of deferred taxes. However,taxes for prior years of exemption or exclusion
may be recoverable if it is later determined that the property did not actually qualify for exemption or exclusion for those prior years.
[ ] G.S. 105-275(8) Pollution abatement/recycling [ ] G.S. 105-278.5 Religious educational assemblies
[ ] G.S. 105-275(17) Veterans organizations [ ] G.S. 105-278.6 Home for the aged,sick,or infirm
[ ] G.S. 105-275(18),(19) Lodges,fraternal &civic purposes [ ] G.S. 105-278.6 Low-or moderate-income housing
[ ] G.S. 105-275(20) Goodwill Industries [ ] G.S. 105-278.6 YMCA,SPCA, VFD,orphanage
[ ] G.S. 105-275(45) Solar energy electric system [ ] G.S. 105-278.6A CCRC-Attach Form AV-11
[ ] G.S. 105-275(46) Charter school property [ ] G.S. 105-278.7 Other charitable, educational, etc.
[ ] G.S. 105-277.13 Brownfields-Attach brownfields agreement [ ] G.S. 105-278.8 Charitable hospital purposes
[ ] G.S. 105-278.3 Religious purposes [ ] G.S. 131A-21 Medical Care Commission bonds
[ ] G.S. 105-278.4 Educational purposes(institutional) [ ] Other:
Tax Deferment Programs—Check the tax deferment program for which this application is made. ***These programs will result in
the creation of deferred taxes that will become immediately due and payable with interest when the property loses eligibility. The
number of years for which deferred taxes will become due and payable varies by program. Read the applicable statute carefully.***
[ I G.S. 105-275(12) Nonprofit corporation or association organized to receive and administer lands for conservation purposes
[ ] G.S. 105-275(29a) Historic district property held as a future site of a historic structure
[ ] G.S. 105-277.14 Working waterfront property
[ ] G.S. 105-277.15A Site infrastructure land
[ I G.S. 105-278 Historic property-Attach copy of the local ordinance designating property as historic property or landmark.
[ ] G.S. 105-278.6(e) Nonprofit property held as a future site of low-or moderate-income housing
Describe the property:
Describe how you are using the property. If another organization is using the property, give their name, how they are using the
property,and any income you receive from their use:
AFFIRMATION: I,the undersigned, declare under penalties of law that this application and any attachments are true and correct to
the best of my knowledge and belief. I have read the applicable exemption or exclusion statute. I fully understand that an ineligible
transfer of the property or failure to meet the qualifications will result in the loss of eligibility. If applying for a tax deferment
program, I fully understand that loss of eligibility will result in removal from the program and the immediate billing of deferred taxes.
Signature(s)of Owner(s): Title: Date:
(All tenants of a tenancy Title: Date:
in common must sign.) Title: Date:
The Tax Assessor may contact you for additional information after reviewing this application.
OFFICE USE ONLY: [ ]APPROVED [ ]DENIED BY: REASON FOR DENIAL: