NCG020847_Rescission Request_20200102

Division of Energy, Mineral & Land Resources
' Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environments
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (orj Certificate of Coverage
N I C I S I I I I N I C I G
2) Owner/Facility Information: "Final correspondence will be mailed to the address noted below
Owner/Facility Name
Facility Contact
Street Address
City
County
Telephone No.
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
LNp Facility closed or is closing on 3'}�J All industrial activities have ceased such that no discharges of
stormwat a e contaminated by exposure to industrial activities or materials. mco-"l f -V. Q n `tA I, 1
❑ Facility sold to on If the facility will continue op re ations under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
❑ Other:
4) Certification:
i, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
subject facility. I am familiar with the information contained in this request and to the best of my knowledge and belief
such information is true, complete and accurate.
Signature Date
Print or type name of person signindabove Title
Please return this completed rescission request form to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 20183an10

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENTAL QUALITY
INVOICE
Annual Permit Fee
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Open
This annual fee is required by the North Carolina Administrative Code, It covers the administrative costs associated with
your permit. It is required of any person holding a permit for any time during the annual fee period, regardless of the facility's
operating status. Failure to pay the fee by the due date will subject the permit to revocation. Operating without a valid
permit is a violation and is subject to a $10,000 per day fine_ If the permit is revoked and you later decide a permit is
needed, you must reapply, with the understanding the permit request may be denied due to changes in environmental,
regulatory, or modeling conditions.
Invoice Number. 2019PR011076
Permit Number: NCG020847
Carteret County
Anna Wink Mine
Larry W. Styron
Larry Styron
PO Box 1834
Morehead City, NC 28557
Payment Options:
Annual Fee Period: 2020-01-01 to 2020-12-31
Invoice Date: 12/0312019
Due Date: 0110212020
Annual Fee: $100.00
1. Electronic payment is convenient and quick_ To pay by ePayment, type"https://deq.nc.govlepaymentsistorrnwater' into your
browser_ If you select eCheck, there wilf be no convenience fee, The convenience fee for a credit card is 2.65% and the
convenience fee for a debit card is $3.95.
2. To pay by mail, please make your check payable to "DEMLR Stormwater Program' and include the 'invoice number on the check.
Then, detach the invoice below and write the check number on the invoice. A $25.00 processing fee will be charged
for returned checks in accordance with N.C. General Statute 25-3-512_
Remit payments by mail to:
NCDEQ -Division of Energy, Mineral and Land Resources
Attn: Stormwater Billing
512 N. Salisbury Street
1612 Mail Service Center
Raleigh, NC 27699-1612
3. Non-payment of this fee by the payment due date will initiate the permit revocation process.
4. Please include your permit number in all correspondence.
5_ Should you have any questions, please contact the Fee Coordinator at [phone].
(Return This Portion With Check)
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2 0 1 9 P R 0 1 1 0 7 6 X
ANNUAL PERMIT INVOICE
Open
Invoice Number: 2019PRO11076
Permit Number. NCG020847
Carteret County
Anna "rink Mine
Lary VV. Styron
Larry Styron
PO Box 1834
Morehead City, NC 28557
Annual Fee Period. 2020-01-01 to 2020-12-31
Invoice Date: 121312019
Due Date_ 11212020
Annual Fee: $100.00
Check Number_