NCG080830_Rescission Request Form_20220413

RECEIVE®
FOR AGENCY USE ONLY
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Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
Rescission Request Form
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
stormwater Program, 1612 Mail Service Center, Raleigh, NC 27699-1612. The submission of this form does not
guarantee recission of your NPDES stormwater permit. Prior to the recession of your NPDES stormwater permit, a
site inspection will be conducted.
1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
A & G TERMINALS LLC
Legally responsible person as signed in Item (4) below:
DINAH CRUSE
Street address:
City:
State and zip code:
9500 NEUVILLE AVE
HILDEBRAN
NC 28637
Telephone number:
Email address:
828-397-2900
2. Industrial Facility (facility requesting rescission):
Facility name:
MFX LLC
Street address:
9500 NEUVILLE AVE/PO BOX 1790
City:
State:
I
Zip Code:
County:
HILDEBRAN
NC
28637
BURKE
Permit Number to which this request applies:
NCGO80830
3. Reason for rescission Request
M'Facility is closed or closing. All industrial activities have ceased such that no discharges of stormwater are contaminated
by exposure to industrial activities or materials.
Date closed/dosing: 9/30/2021
Facility sold.
Sold to:
On date:
Other (please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.66 (i) 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 this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
O I, as an authorized representative, hereby request recission 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.
Printed Name of Person Signing: DINAH M CRUSE
Title: CFO
(Signature of Applicant)
4/06/2022
(Date Signed)
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC27699-1612 —
Page 2 of 2

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENTAL QUALITY
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INVOICE � i o x x r a a a t o t i
Stormwater Annual Permit Fee Open
This Stormwater annual fee is required by the North Carolina Administrative Code 143-215.D(a). It covers the administrat
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 lat
decide a permit is needed, you must reapply, with the understanding the permit request may be denied due to changes it
environmental, regulatory, or modeling conditions.
Invoice Number: 2022PR001041
Permit Number: NCG080830
Burke County_
A & G Terminals, LLC
Alan Dietz
A & G Terminals LLC
PO Box 1790
Hildebran, NC 28637
Annual Fee Period: 2022-03-01 to 2023-02-28
Invoice Date: 02/02/2022
uue uate: ua/urNLI
Annual Fee: $100.00
Payment Options:
1. Electronic payment is convenient and quick. To pay by ePayment, type "hops://deq.nc.gov/epayments/stormwatee' into your
browser. If you select eCheck, there will 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 aziza.selkane ncdenr. ov or [phone].
(Return This Portion With Check)
* 2 0 2 2 P R 0 0 1 0 4 1
ANNUAL PERMIT INVOICE
Open
Invoice Number: 2022PR001041
Permit Number: NCG080830
Burke County
A & G Terminals, LLC
Alan Dietz
A & G Terminals LLC
PO Box 1790
Hildebran, NC 28637
Annual Fee Period: 2022-03-01 to 2023-02-28
Invoice Date: 2/2/2022
Due Date: 3/4/2022
Annual Fee: $100.00
Check Number: