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Home My WebLink AboutNCG020603_Rescission Request_20241022 FOR AGENCY USE ONLY �d�0 Assigned to: C/ oK ARO FRO MRO RRO WARD IR WSRO 9TFpp 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 recission 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: Legally responsible person as signed in Item(4)below: Delilah Smith Christopher Smith POA for Delilah Smith Street address: City: State and zip code: 1982 R.B. Lane SW Supply NC 28462 Telephone number: Email address: (931)980.4050 2. Industrial Facility(facility requesting rescission): Facility name: Civietown Mine-Supply Owner: Delilah Smith Street address: 1982 R.B. Lane SW City: State: Zip Code: County: Supply I NC 28462 Brunswick Permit Number to which this request applies: NCG020603 3. Reason for rescission Request This is required information.Attach separate sheets if necessary. El 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/closing: Approximately 2009 E3 Facility sold. Sold to: On date: E30ther(please explain): 4. Applicant Certification: North Carolina General Statute 143-215.6E(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($50,000). 1 hereby request exclusion from NPDES stormwater permitting. Under penalty of law,I certify that: O I,as an authorized representative, hereby request recission of coverage under the NPDES stormwater Permit for the subject facility. I am familiar with the information contained in this request and to the best of my knowledge and belief such information is true,complete,and accurate. Printed Name of Person Signing: Christopher Smith, POA for Delilah Smith Title:Son/POA for Delilah Smith I D�3,—k- >7 Oct 2024 (Signature of Applicant) (Date Signed) Mail the entire package to: DEMLR—Stormwater Program Department of Environmental Quality 1612 Mail Service Center Raleigh, NC 27699-1612 Page 2 of 2 FILED WILKES COUNTY MISTY M. SMITHEY IIIIIII IIIIIIIIIIIII IIIIIillll IIIIIII 85067 P0669m o04 02.000 REGISTER OF DEEDS ns PROP Brunswick County, NC Register of Deeds page I of 3 n'I FILED Aug 01, 2023 Retum toop � �o AT 09:33:05 am Totel`-pp{��„ n 2�int._ _ BOOK 01380 3 CkS 'd(p_ ck# ?5Cashs__-- PAGE 0110 Refund— _ Cash$ Finance_ aia iMgibin dnv t INSTRUMENT # 05043 ` EXCISE TAX (None) :x•. t ^tarn-ssa+sverifecty •qc.n: stnment:h21 cannot t,,e reproduced c:cOr r:.. 3" top margin required by Register of Deeds North Carolina Durable Power of Attorney 1. DESIGNATION OF AGENT: 1, Delilah Smith, name my son, Christopher D. Smith as my Agent: 761 Heritage Trace Cadiz, KY 42211 931-980-4050 I give to my acting agent the full power to appoint another to act as my agent, and full power to revoke such appointment. 2. GRANT OF SPECIAL AUTHORITY I grant my agent and any successor agent general authority to act for me with respect to the following subjects as defined in the North Carolina Uniform Power of Attorney Act, Chapter 32C of the General Statutes: a. Real Property b. Tangible Personal Property C. Stocks and Bonds d. Commodities and Options e. Banks and Other Financial Institutions f. Operation of Entity or Business g. Insurance and Annuities h. Estates,Trusts, and Other Beneficial Interests Initial: till II IIIIIIIIIIIII IIIIIIIII IIIIIIII R P0670m ns-PR P — Brur wick County,_NC-Reglster-cf"Deeds page 2 of 3 i. Claims and Litigation j. Personal and Family Maintenance k. Benefits from Governmental Programs or Civil or Military Service 1. Retirement Plans In. Taxes 3. GRANT OF SPECIFIC AUTHORITY: My agent shall also have the following specific authority: a. Make a gift, subject to the limitations provided in G.S.32C-2-217 b. Waive my right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan C. Exercise fiduciary powers that I have authority to delegate d. Disclaim or refuse an interest in property, including a power of appointment e. Access the content of electronic communications. My agent shall not have the specific authority to do the following acts: a. Create or change rights of survivorship b. Create or change a beneficiary designation 4. ADDITIONAL PROVISIONS AND EXCLUSIONS: None 5. EFFECTIVE DATE: This power of attorney is effective immediately. 6. NOmmnON OF GUARDIAN: If it becomes necessary for a court to appoint a guardian of my estate or a general guardian, I nominate my agent acting under this power of attorney to be the guardian to serve without bond or other security. 7. RELIANCE ON THIS POWER OF ATTORNEY: Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that person knows it has terminated or is invalid. 8. MEANING AND EFFECT: The meaning and effect of this power of attorney shall for all purposes be determined by the law of the State of North Carolina. Initial/ ,VJ ti- 7�. . IIII II I IIII II I IIII II IIIII III IIIIII III Brenda5067 P0671 n�12 04 022PR0 Brunswick CoOP unty, NC Register of Deeds page 3 of 3 9.SIGNATURE AND ACKNOWLEDGEMENT: This the day of �P�_e l ��— .2022. (SEAL) Defirah Smith, Principal STATE OF NORTH CAROLINAI COUNTY OF r WI[_I�C-- I certify that Delilah Smith personally appeared before me this day, acknowledging to me that he or she signed the foregoing document for the purposes therein expressed. This the 25 day of_{z,�C_ 2022. C G-- Signature ofKoq0iy Public Printed Name: My Commission Expires: (SEAL) EUOENE COX NOTARY PUBLIC PREPARED BY: SnPNANIEa.IRVlNE BrUOSWICk County IRVINE LAW nml,PLLC North Carolina 825-C MERRIMON AVE#321 NMI Ql laaloe Expires 00 25,2026 ASNEVILLE.,NC28804 ------' — WWW.IRVINELAWFIR.N.COM Initial: