NCC210642_Annual Fee Invoice_20230201

North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources
Stormwater Program
NPDES Construction Stormwater Permit
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copwl .^;a�E° ,`�^p^� � INVOICE
Annual Permit Fee
his Construction Stormwater annual fee is required by the North Carolina Administrative Code 143-215.D(a).
he fee covers the administrative costs associated with your permit. The fee is required of any person holding a
ermit for any time during the annual fee period, regardless of the facility's operating status. Failure to pay the
�e by the due date will subject the permit to revocation. Operating without a valid permit is a violation and is
abject to a $10,000 per day fine. If the permit is revoked and you later decide a permit is needed, you must
apply, with the understanding the permit request may be denied due to changes in environmental,
?gulatory, or modeling conditions.
Invoice No: NCC210642-2023
Certificate of Coverage No.: NCC210642
Effective Date: 2/19/2021
Project Name: CaroMont Regional Medical
Center - Belmont
!gaily Responsible Person:
ichard Blackburn
aroMont Health, Inc.
25 Court Drive
istonia, NC
054-2140
nvoice Date: 2/1/2023
)ue Date: 3/1/2023
nual Fee Period: Feb 2023 to Feb 2024
nual Fee: $100
[e-mail]
Telephone: [phone]
Site Contact: Dave Hultstrand
ite Contact E-mail:
[e-mail]
:tropic payment option is preferred. Type https://deg.nc.gov/SW-epayments into your browser. If you
!ct eCheck, there is no convenience fee. The convenience fee for a credit card is 2.65% and the convenience
for debit card is $3.95.
If you must pay with paper check, please make your check payable to "DEMLR Stormwater Program" and
include the Certificate of Coverage No. in the memo field alone with a coov of this invoice.
$25.00 processing fee will be charged for returned check in accordance with North Carolina General Statute
i-3-512. Contact Tev Holloman at [e-mail] or [phone] with any questions.
to: NCDEQ— Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh NC 27699-1612
this project has been closed out or sold, you must submit a Notice of Termination (NOT) request here:
tps://edocs.deg.nc.gov/Forms/NCG01-Termination (New owners must obtain a new COC)