NCG020311_COMPLETE FILE - HISTORICAL_20060607

STORMWATER-DIVISION CODING -SHEET -
RESCISSIONS.
PERMIT NO.
nlLl-2(��l��j�I
DOC TYPE
COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
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YYYYMMDD

W fi r4S9PG Michael F. Easley, Governor
William G. Ross Jr,, Secretary
North Carolina Department of Environment and Natural Resources
[3 -� Alan W. Klimek, P.E. Director
y Division of Water Quality
June 7, 2006
Mr. Fred Sawyer
Fred Sawyer Mine
104 Russell Ln.
Elizabeth City, NC 27909
Subject: Stormwater General Permit NCG020000
Operations and Maintenance Reminder
Fred Sawyer Mine
COC Number NCG020311
Pasquotank County
Dear Permittee:
Our records indicate that you have been issued a Stormwater General Permit and a Certificate of
Coverage for your facility. These permits have specific conditions that must be met in order for you to
be in compliance with your permit. It is your responsibility, as the permit holder, to read and comply
with the conditions contained in the permit.
It is our responsibility, as the issuing authority, to make sure that the operation and maintenance of
your facility complies with the conditions contained in your permit. To assist you in complying with
these conditions, we are attaching a Technical Bulletin specific to your permit requirements. We are
currently in the process of developing our inspection schedule. Therefore, you should have all of
your records up to date as we may be contacting you in the near future to'set up an inspection of your
facility.
If you have any questions, please do not hesitate to contact Samir Dumpor, Pat Durrett or myself at
[phone].
Sincerely
r-c-Q-- Al Hodge, Supervisor
Washington Regional Office
Surface Water Protection Unit
Encl.
CC: WaRO files
North Carolina Division of Water Quality lntemet: h2o.enr.statemc.us
943 Washington Square Mall Phone: [phone] One
Washington, NC 27889 FAX [phone] NorthCarolina
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O�0F WAT �y Michael F. Fasley, Governor
William G. Ross Jr., Secretary
North Carolina Department ol' Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Witter Qu!dity
February 7, 2005 R�'�ECEgV
Fred Sawyer Fred Sawyer Mine FEB C 1 2005
104 Russell Ln
Elizabeth City, NC 27909 DWQ-WARD
Subject: NPDES Stormwater Permit Coverage Renewal
Fred Sawyer Mine
COC Number NCG020311
Pasquotank County
Dear Permittee:
In response to your renewal application for continued coverage under general permit NCG020000 the Division of Water
Quality (DWQ) is forwarding herewith the reissued stormwater general permit. Please review the new permit to familiarize
yourself with the changes in the reissued permit. The general permit authorizes discharges of Stormwater and some types of
wastewater. You must meet the provisions of the permit for the types of discharges present at your facility. This permit is
reissued pursuant to the requirements of North Carolina General. Statute 143-215.1 and the Memorandum of Agreement
between the state of North Carolina and the U.S. Environmental Protection Agency, dated December 6, 1983.
The following information is included with your permit package:
• A new Certificate of Coverage
• A copy of General Stormwater Permit NCG020000
• A copy of a Technical Bulletin for the general permit
• Five copies of Discharge Monitoring Report (DMR) Forms - wastewater and stormwater
• Five copies of Qualitative Monitoring Report Form
Your coverage under this general permit is not transferable except after notice to DWQ. The Division may require modification
or revocation and reissuance of the Certificate of Coverage. This permit does not affect the legal requirements to obtain other
permits which may be required by DENR or relieve the permittee from responsibility for compliance with any other applicable
federal, state, or local law, rule, standard, ordinance, order, judgment, or decree.
If you have any questions regarding this permit package please contact Bethany Georgoulias of the Central Office Stormwater
Permitting Unit at [phone], ext.529.
Sincerely,
for Alan W. Klimek, P.E.
cc: Central Files
Stormwater & General Permits Unit Files
Washington Regional Office
One
islo it3Carollna
,lVattirallf
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet: h2o.enr.state.nc.uslsulstormwater.html 512 N. Salisbury St. Raleigh, NC 27604 FAX [phone]
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STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG020000
CERTIFICATE OF COVERAGE No. NCG020311
STORMWATER AND PROCESS WASTEWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
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,
Fred Sawyer Mine
is hereby authorized to discharge stormwater and to operate treatment systems and discharges associated
with mine dewatering wastewater and process wastewater from a facility located at
Fred Sawyer Mine
104 Russell Ln
Elizabeth City
Pasquotank County
to receiving waters designated as Newbegun Creek, a class C-Sw stream in the Pasquotank River Basin in
accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Parts I, II,
III, IV, V, and VI of General Permit No. NCG020000 as attached.
This certificate of coverage shall become effective February 7, 2005.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day February 7, 2005
for Alan W. Klimek, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission

C)
_co
0
0�
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
4/13/2004 �y
CERTIFIED MAIL RECEIVED
RETURN RECEIPT REQUESTED
Fred Sawyer APR i 0 2004
Fred Sawyer Mine
104 Russell Ln
Elizabeth City NC 27909 DWQ-WARD
SUBJECT: NOTICE OF VIOLATION AND REVOCATION FOR NON PAYMENT YK r�
PERMIT NUMBER NCG020311
Fred Sawyer Mine
Pasquotank COUNTY
Dear Permittee:
Payment of the required annual administering and compliance monitoring fee of $80.00 for this year has not
been received for the subject permit. This fee is required by Title 15 North Carolina Administrative Code 2H.0105, under
the authority of North Carolina General Statutes 143-215.3(a)(1), (1 a) and (1 b). Because this fee was not fully paid within
30 days after being billed, this letter initiates action to revoke the subject permit, pursuant to 15 ncac 2H.0105(b) (2) (k)
(4), and G.S. 143-215.1 (b) (3).
Effective 60 days from receipt of this notice, subject permit is hereby revoked unless the required Annual
Administering and Compliance Monitoring Fee is received within that time. Discharges without a permit are subject to the
enforcement authority of the Division of Water Quality. Your payment should be sent to:
N.C. Department of Environment and Natural Resources
Division of Water Quality
Budget Office
1617 Mail Service Center
Raleigh, NC 27699-1617
If you are dissatisfied with this decision, you have the right to request an administrative hearing within Thirty (30)
days following recipt of this notice, identifying the specific issues to be contended. This request must be in the form of a
written petition conforming to Chapter 150B of the North Carolina General Statutes, and filed with the Office of Administrative
Hearings, Post Office Drawer 27447, Raleigh, North Carolina, 27611-7447. Unless such request for hearing is made or
payments received, revocation shall be final and binding. if you have any questions, please contact:
r'Mr. Jim Mulligan, Washington Water Quality Regional Supervisor, [phone]. J
Sincerely,
h
Alan W. Klimek, P.E.
cc: Supevisor, Water Quality Permits and Engineering Unit
Washington Regional Office
County Health Department
1617 Mail Service Center, Raleigh, NC 27699-1617 Telephone [phone] FAX [phone]
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Michael E. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
d
4/24/2003
CERTIFIED MAIL
Alan W. Klimek, P.E. Director
Division of Water Quality
RETURN RECEIPT REQUESTED RECEIVED
Fred Sawyer
Fred Sawyer Mine
104 Russell Ln APR 2 9 2003
Elizabeth City NC 27909
SUBJECT: NOTICE OF VIOLATION AND REVOCATION FOR NON PAYMENT DWQ_WARQ
PERMIT NUMBER NCG020311
Fred Sawyer Mine
Pasquotank COUNTY
Dear Permittee:
Payment of the required annual administering and compliance monitoring fee of $80.00 for this year has not
been received for the subject permit. This fee is required by Title 15 North Carolina Administrative Code 2H.0105, under
the authority of North Carolina General Statutes 143-215.3(a)(1), (1a) and (1b). Because this fee was not fully paid within
30 days after being billed, this letter initiates action to revoke the subject permit, pursuant to 15 ncac 2H.0105(b) (2) (k)
(4), and G.S. 143-215.1 (b) (3).
Effective 60 days from receipt of this notice, subject permit is hereby revoked unless the required Annual
Administering and Compliance Monitoring Fee is received within that time. Discharges without a permit are subject to the
enforcement authority of the Division of Water Quality. Your payment should be sent to:
N.C. Department of Environment and Natural Resources
Division of Water Quality
Budget Office
1617 Mail Service Center
Raleigh, NC 27699-1617
If you are dissatisfied with this decision, you have the right to request an administrative hearing within Thirty (30)
days following recipt of this notice, identifying the specific issues to be contended. This request must be in the form of a
written petition conforming to Chapter 150B of the North Carolina General Statutes, and filed with the Office of Administrative
Hearings, Post Office Drawer 27447, Raleigh, North Carolina, 27611-7447. Unless such request for hearing is made or
payments received, revocation shall be final and binding. If you have any questions, please contact:
Mr. Jim Mulligan, Washington Water Quality Regional Supervisor, [phone].
Sincerely,
E
cc: Supevisor, Water Quality Permits and Engineering Unit
Washington Regional Office
County Health Department
1617 Mail Service Center, Raleigh, NC 27699-1617 Telephone [phone] PAX 919-733-9919
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-- :ate of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
December 17, 1999
FRED SAWYER
FRED SAWYER SAND PIT
104 RUSSELL LANE
ELIZABETH CITY, INC 27909
Subject
Dear Permittee:
LTWA
4 0 •
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCrS
Vl
(( i
flip DEC 1 5 1999
Reissue - NPDES Stormwater Perml t TOtj R i OtiAL OFFICE
Fred Sawyer Sand Pit
COC Number NCG020311
Pasquotank County
In response to your renewal application for continued coverage under general permit NCG020000, the Division of
Water Quality (DWQ) is forwarding herewith the reissued stormwater general permit. This permit is reissued
pursuant to the requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement
between the state of North Carolina and the U.S. Environmental Protection Agency, dated December 6, 1983.
The following information is included with your permit package:
* A copy of general stormwater permit NCG020000
* Five copies of the Analytical Monitoring form and five copies of the Qualitative Monitoring form
* A copy of a Technical Bulletin on this permit which outlines permit components and
addresses frequently asked questions
* A Certificate of Coverage for your facility
* DWQ fee schedule
Your coverage under this general permit is not transferable except after notice to DWQ. The Division may require
modification or revocation and reissuance of the Certificate of Coverage. This permit does not affect the legal
requirements to obtain other permits which may be required by DENR or relieve the permittee from responsibility
for compliance with any other applicable federal, state, or local law rule, standard, ordinance, order, judgment, or
decree.
Please note that in 1998 Senate Sill 1366 established changes to the permit fee structure for DWQ permits effective
January 1, 1999. This change requires that you pay an annual fee to assure continued coverage under this permit.
You will be invoiced for this fee beginning next year. A copy of the current fee schedule is included with this letter.
If you have any questions regarding this permit package please contact Tony Evans of the Central Office Stormwater
and General Permits Unit at [phone], ext. 584
Sincerely,
b'�J/ � "'�
for Kerr T. Stevens
Director, Division of Water Quality
cc: Central Files
Washington Regional Office `
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] FAX [phone]
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STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG020000
CERTIFICATE OF COVERAGE No. NCG020311
STORMWATER AND PROCESS WASTEWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
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,
FRED SAWYER SAND PIT
is hereby authorized to discharge stormwater and to operate or continue operation of treatment systems and
discharges associated with mine dewatering and process wastewater from a facility located at
FRED SAWYER SAND PIT
104 RUSSELL LANE
ELIZABETH CITY
PASQUOTANK COUNTY
to receiving waters designated as Newbegun Creek in the Pasquotank River Basin in accordance with the effluent
limitations, monitoring requirements, and other conditions set forth in Parts 1, I1. III, IV, V, and VI of General
Permit No. NCG020000 as attached.
This certificate of coverage shall become effective December 17, 1999.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day December 17, 1999.
� A e w
for Kerr T. Stevens, Director
Division of Water Quality
By Authority of the Environmental Management Commission

State of North Carolina
Department of Environment,
Health and,Natural Resources 4 •
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary C) F—Z=
A. Preston Howard, Jr., P.E., Director - RECEIvED
WASHINGTON OFFICE
AUG 1 61995
August 11, 1995 a M.
Mr. Fred Sawyer --
104 Russell Lane
Elizabeth City, NC 27909
Subject: General Permit No. NCG020000
Sawyer, Russell
COC NCG020311
Pasquotank County
Dear Mr. Sawyer:
In accordance with your application for discharge permit received on July 10, 1995, we are forwarding
herewith the subject certificate of coverage to discharge under the subject state - NPDES general permit. This
permit is issued pursuant to the requirements of North Carolina General Statute 143-215 .1 and the
Memorandum of Agreement between North Carolina and the US Environmental Protection agency dated
December 6, 1983.
If any parts, measurement frequencies or sampling requirements contained in this permit are
unacceptable to you, you have the right to request an individual permit by submitting an individual permit
application. Unless such demand is made, this certificate of coverage shall be final and binding.
Please take notice that this certiftcate.of coverage is not transferable except after notice to the Division
of Environmental Management. The Division of Environmental Management may require modification or
revocation and reissuance of the certificate of coverage.
This permit does not affect the legal requirements to obtain other permits which may be required by the
Division of Environmental Management or permits required by the Division of Land Resources, Coastal Area
Management Act or any other Federal or Local governmental permit that may be required.
If you have any questions concerning this permit, please contact Bill Mills at telephone number 9ign33-5083.
Sincerely, on inal Figned BY
Cr,)1leork H. bulllr-5
A. Preston Howard, Jr., P. E.
�cc Washingfon Regioal-Officey
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] 'FAX [phone]
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-if;

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT
GENERAL PERMIT NO. NGCO20000
CERTIFICATE OF COVERAQE NO. NCG020311
STORMWATER, MINE DEWATERING, AND/OR OVERFLOW FROM
PROCESS WATER RECYCLE SYSTEMS DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION _SYSTEM
In compliance with the provision of North Carolina General Statute 143-2t5.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the
Federal Water Pollution Control Act, as amended,
Fred Sawyer
is hereby authorized to discharge mine &watering and stormwater from a facility located at
Fred Sawyer Sand Pit
Pitts Chapel Road
Elizabeth City
Pasquotank County
to receiving waters designated as New Begun Creek in the Pasquotank River Basin
in accordance with the effluent limitations, monitoring requirements, and other conditions set forth in Ruts 1, 11, 1I1
and IV of General Permit No. NCG020000 as attached.
This Certificate of Coverage shall become effective August 11, 1995,
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day August 11, 1995.
A. Preston Howard, Jr., P.E., Director
Division of Environmental Management
By Authority of the Environmental Management Commission

DEPARTMENT OF NATURAL RESOURCES
AND COMMUNITY DEVELOPMENT '
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Stal'e'of North Carolina
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
Mr. Fred Sawyer
104 Russell Lane
Elizabeth City, North Carolina 27909
Dear Mr. Sawyer:
YA.WA1•
L3EHNF�
WASHINGTON OFFICE
July 19, 1995 'JU!_ 2 5 1995
D. E. M.
Subject: Application for Stormwater Permit
Fred Sawyer Sand Pit
Pasquotank County
The Notice of Intent (NOI) form which you filed with our office on July 10, 1995 was the wrong
form. You filed the form for General Permit NCG030000 which is for activities engaged in
manufacturing equipment and metal parts. You should have filed a form for General Permit
NCG020000 which is the permit for mining activities and includes stormwater, process wastewater
(wash water for stonewashing, etc.) and mine dewatering. Enclosed is a copy of the proper form.
On the form you filed, you had not completed any of the information required on page 2 of the
form. You must complete all of the questions on the form I am enclosing herein for NCG020000.
If you don't have a vicinity map, that is not a problem. I will get a copy of one from Tracy Davis
at the Land Quality Program since they are currently processing your Mining Permit application.
Your application filing fee of $400 has already been deposited and will be applied to the new form
when we receive it.
We will not be able to process the application further until we receive this form for NCG020000
filled out completely. Please call me if I may be of assistance in clarifying the information needed. .
My phone number is 919 733-5083 extension 548. I am typically in the office 9 to 6 Monday
through Friday.
Sincerely,
Rilm C. Mills, P. E.
Environmental Engineer
Permits and Engineering Unit
cc: Tra avis, Land Quality Section
ill Moore, WaRO
Attachment: NCG020000 Notice of intent Forms
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
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''-' r LEXR9;E
Fax:[phone] Aug 7 '95 16:57 P.01/05
DIVISION OF E1 VI gNMENTAL MANAGEMENT RECEIVED
�• WA5HINGTON OFFICE
AUGUST 7, 199 S
Aa)G 0 8 1995
TO: ROBERT TANKARD
WARO D. E M.
FROM: BILL MILLS
P&E
SUBJECT: NOI FOR MINING (FRED SAWYER SAND PIT)
NCG020311
PASQUOTANK COUNTY
This NOI did not get included in the list that went to regional offices
last month. There was some mix up in the listing. This guy
apparently was operating a sand pit without mining permits. Mining
hit him up for a fine. He made a settlement with Land Quality which
he has apparently paid. The mining permit was issued last week. He
must have his storinwater permit before he can go back to work.
Please give me your OK at an early date if you have no problem with
issuance of the. CofC for this one. Looks like he has paid for his sins
(of ommission) and we might as well move it out unless you see
some problem.
If you cannot get me on phone, leave a message Ext. 548,
Thanks for your help and keep those fish alive out there.

DEM-P &. E Fax:[phone] Aug 7 '95 16:58 P.02/05
uS1E QKLT
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
NOTICE OF INTENT REQUESTING COVERAGE UNDER THE
MINING ACTIVITIES GENERAL NPDES PERMIT NCO020000
Complete this Notice of Intent a6101) and mail to the foibwinp address
North Carolina Mition of Environments! Wrreparrent
Water Duality Section. NPDES Group,
P.U. Box 29=
lkaleiah, North Caroline, 2762"535
Ttze NOI must be accompanied with a general permit fifino tee of $400.00, The check should tee
made out to the North Carolina Npartment of Environment, Health, and Natural Resources.
� 11 *i1 • 4 • 1 ! /li � • 1
City: El `.-Laid-1��1 - .. - state:.- V Ile r
zip: 7 9a Phone: 3-3'r'
Name:
Address:
Ctty: ' State: NX, Zap: J ? �D 2
county: i pry�..�-�.� J �Phone 1919 t Sa 5- &'0:51
wwllNM 1
Physical Location Information:
(Street address, stato road number, distance and direction from roadway Intersection, VW
attach a copy of a county or USGS quad with the location of the facility marked orV the map.)
1 , i .41 . 1 1 1 . '11
(Agency use only: ' Latitude
NOI 02 PAGE 1

BEM-P 9,E Fax:[phone] Aug 7 '95 16:58 P.03/05
Type of minerals mind at this facility,
Standard Industrial Classification (SIC CODE) (for activity for which the facility is
primarily engaged)
This Is an , existing faalilty or a — proposed facility.
If proposed, date operation is to begin
Discharges are to
01 (name of reoelving waters or, if to a separate
storm sewer system, name of the separate Storm sewer system)
A. Does this facility have any NPDES Permits? _yes Xno If yes, NPDES No.
B. Ara vehicle maintenance activities o=rrin0 on site? T yes Xrto
C. Are mine dewatering discharges occurring? X yes no
D. Are discharges of overflows from process wastewater treatment systems occurring?—yesKno
If yes, complete the following on the wastewater treatment system:
1. Please describe the type of process used to treat and/or rewyole the prooess
wastewater, Chive design specifics (i.e. design volume. retention time, surface area,
etc.). Existing treatment facilities should be described in detail and design criteria or
operational data should be provided (including calculations) to ensure that the facility
can comply with requlrsmenit; of the General Permitti�
NOTE: Construction of any wastewater treatment facilities require submission of three (3)
sets vF plans and specifications along with their a Wlication. Design of treatment
facilities must comply with requirements 15A NCAC 2H .0138, If construction of
wastewater treatment facilitiete applies to the discharge of process wastewater,
Include three sets of plains and specifications with this application.
2. Does this facility employ chemical additives to flocculate suspended solids? ;,,_yes „_no
If yes, please stale the name, manufacturer and the quantity of average dally usage of
the chemical additive
3. Does this facility overflow only during - rainfall events exceeding the 10-year, 24-hour
rainfall event? —yes ono
E. Does this facility employ any best management praclleas for wormwater control? __yes ,Vno
It yes, please describe
NOT 02 PAGE 2

DEEM-P &. E Fax :[phone] Aug 7 '95 16:58 P. 04/05
F. Number of dlscharwe points
Mine Dewatering _,, Stormwater
Process Wastewater Overflows
Please provide short narrative description of discharges
t hereby request coverage under the referenced General Permit. I understand that ooverage
under this permit will constitute the permit requirements for the disc arge(s) and is
enforceable In the frame manner as an individual permit.
1 nme to abide by the following es a part of coverage under this General permit:
1. 1 agree to abide by the approved Mining Permit for this mining ao0vity. ( A copy of the valid mining
permit .must, he attached to this 'requait..
2. 1 agree to mt. discharge any sanitary wastawater from this reining activity exoept under the
provisions of another NPDES permit speclficaily Issued therefore.
S. 1 agree that bulk storage of petroleum products and other chemicals shall have adequate protection so
as to contain all split on the *ite.
4. t agree that solid wastes will be disposed of in accordance with N.C. statutes and rules govarning
solid waste disposal.
S. I agree that maintanance sotivitioa for vehiclea end heavy equipment will be performed so as to not
result Its contamination of the surfaco or ground watars.
I agree to abide by the provisions no listed abovo and recognize that the provisions are to be considered
= enforceable requirements of the General Porrhit.
1 certify that I am familiar with the Information contained in the a"lloation and that to the beat of my
knowledge and ballet such Information is trios, complete, and accurate.
siprteture data:
.P• _�. Ilr1 t.1o. ✓ W 0/'01
name or person signing a (printed or typal) tltlta
North Carolina General Statute 143-215.6B (() 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 AnWe 21 or repulgtsons of the
environmental Management Commission Implementing that Articla, or who falsifies, tampons
with or knowingly renders inaccurate any recording or monitoring_device or method required to
be operated or maintained under Article 21 or regulations of the Environmental Management
Commission Implementing that Article,. shall be guilty of a misdemeanor punishable by a fine
not to exceed $10.000, or by Imprisonment not to excood six months, or by both. (10 U.S.G.
Section 1001 provides a punishment by a fine of not more Than $10.000 or Imprisonment not
more than 5 years, or both, for similar offense.)
Rol 02 PAGE 3

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