NCS000594_Public Notice Affadavit_20190130

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Media of Eastern North Carolina
The Daily Reflector - The Daily Advance - The Rocky Mount Telegram
Bertie Ledger - Chowan Herald - Duplin Times - Farmville Enterprise - Perquimans Weekly - Standard Laconic
Tarboro Weekly -Times Leader- Wiliamston Enterprise
PO Box 1967 Greenville NC 27835 - [phone]
Name: NC DIVISION ENERGY MINERAL LAND
RESOURSE
Address: 512 N. SALISBURY ST
1612 MAIL SERVICE CENTER
RALEIGH NC 27699
N
Ticket: 267702
Copy Line: STORMWATER DISCHARGE PERMIT
Total Price: $75.20
Run Dates: 12/04/18 to 12/04/18
Paper: Rocky Mount Telegram
PAY THIS AMOUNT $75.20
DUE IN 10 DAYS
K13
DENR-LAi`1D QUALITY
STORMWWi'ER PERIOTTiNG
Please return bottom portion with payment to ensure your payment is posted properly.
Ticket: 267702
Account ID: 144263
Copy Line: STORMWATER DISCHARGE PERMIT
IMPORTANT NOTICES
This is a statement for the legal ad that ran in
Rocky Mount Telegram
An affidavit will be issued upon receipt of payment for this ad to the
address listed unless we are notified to do otherwise.
There will be a $25.00 fee for each duplicate affidavit.
Bill Date: 12/04/18
Total Price: $75.20
PLEASE REMIT TO:
APG Media
ATTN: Anita House
PO Box 1967
Greenville NC 27835
To make a credit/debit card payment over the
phone, please call [phone].

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Media of Eastern North Carolina
The Daily Reflector - The Daily Advance - The Rocky Mount Telegram
Bertie. t edger - 0howan Herald - rluplin Times - Farmville Enterprise = Perquimans Weekly - Standard I aonnic
Tarboro Weekly - Times Leader- Wlliamston Enterprise Check #
NC DIVISION ENERGY MINERAL LAND
RESOURSE
512 N. SALISBURY ST
1612 MAIL SERVICE CENTER
RALEIGH NC 27699
Account: 144263 Ticket: 267702
PO Box 1967
Greenville NG 27835 Date Paid
ATI .-•
Copy Line: STORMWATER DISCHARGE PER-
MIT
Lines: 39
Total Price: $75.20
PUBLISHER'S AFFIDAVIT
NORTH CAROLINA NC DIV. OF ENERGY, MINERAL
Nash Coun AND LAND RESOURCES'
tY INTENT TO ISSUE A
STORMWATER DISCHARGE
PERMIT
_ affirms that he/she is clerk of Rocky public comment or objection to the
Mount felegram, a newspaper p blished daily at Rocky Mount, North Carolina, draft permit is invited. Submit written
and that the advertisement, a true co of which is hereto attached, entitled comments to commeDEMLRnts
at the address
PY below. All comments received through
STORMWATER DISCHARGE PERMIT was published in said Rocky Mount Tele- January 4, 2019 will be considered in
the final delerrniriatiorrregarding
gram on the following dates: permit issuance and permit provisions.
Tuesday, December 4, 2018
and that the said newspaper in which such notice, paper, document or legal
advertisement was published, was at the time of each and every publication, a
newspaper meeting all of the requirements and qualifications of Chapter 1, Sec-
tion 597 of the General Statutes of North Carolina and was a qualified newspaper
within the meaning of Chapter 1, Section 597 of the General Statutes of North
Caroyina.
n
Affimed and subscribed before me this 4th day of December 2018
(Notary Public Signature)
4�
(Notary Public Printed Name)
My commission expires Lt,[L7W,
IICilItIuH0 1///
NOTARY
PUBLIC
7 �V\o
Application: SePro Development
Company III LLC , 16013 Watson Seed
Rd, Whitakers, NC has applied for an
NPDES permit to discharge stormwater
from an industria I facility at this ad-
dress in Nash County. The facility
discharges to a UT to Fishing Creek
in the Tar -Pamlico River Basin. Permit
NCS000594.
Stormwater Program Contact:
Annette Lucas
[phone]
[e-mail]
A copy of the draft permit is available
at: https://bit.ly/2JSf5ls. Additional per-
mit documents are available for the
reproduction cost at:
DEMLR Stormwater Program
512 N. Salisbury Street
1612 Mail Service Center
Raleigh, NC 27699-1612
12/04/18

NC Office of the
STATE OF NORTH CAROLINA
State Controller
SUBSTITUTE W-9 FORM
(IRS Form W-9 will not be
accepted in lieu of this form)
Request for Taxpayer Identification Number
V '
s
*Denotes a Required Field
1. Social Security Number ISSN),
Please select the appropriate Taxpayer Identification Number (EIN, SSN,
OR
or ITIN) type and enter your 9-digit ID number. The U.S. Taxpayer
Employer Identification Number (EIN),
Identification Number is being requested per U.S. Tax Law. Failure to
OR
El
provide this information in a timely manner could prevent or delay
Individual Taxpayer Identification Number ([TIN)
payment to you or require The State of NC to withhold 28% for backup
�2
withholding tax.
3 8 4 0 1 0 9 6 5
;.
4. Legal Name (as shown on your income tax return):
3. Dunn & Bradstreet Universal Numbering System (DUNS) (see
APG-East LLC
instructio iV ED
S. Business Name/DBA/Disregarded Entity Name, if different from
Legal Name: APG Media of ENC, The Daily Reflector, The Daily
�aN 3 0 2�13
i
Advance, Rocky Mount Telegram
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7 ReinittaneeFlAtldress (Locatiorispeclfx�fi�i mt Ig'
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different frorp_IEegalAddre is, if app]1Cah(b.,!i?.If tl: ' I,}(.
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"Address Line 1:
Address Line 1:
PO Box 1967
Address Line 2:
Address Line 2:
5 .i;1
City *State Zip (9 digit)
City State Zip (9 digit)
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Greenville NC 27835-1967
County
Y
Pitt
l
, .;.
*8. Contact Name'.
Accounting Department
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*9. Phone Number:
252 329-9506
10. Fax Number:
[phone]
11, Email Address:
[e-mail]
k12 Entity Type
r13 Entlty
34 EieMpi<s(see
ron
..,, ,! : . ,.:; , :...
Classification
instructions)
`.
Individual/Sole Proprietor/Single-member LLCGCorporation OS -Corporation
_._
Medical Services
Partnership Trust/Estate El other
® Legal/Attorney
Exempt payee code (if any):
Services
® Limited liability company. Enter the tax classification (C=C corporation,
E] NC Local Govt
S=S corporation, P=Partnership)
Federal Govt
Note: Check the appropriate box in the line above for the tax classification of the single -
NC State Agency
member owner. Do not check LLC if the LLC is classified as a single -member LLC that is
Exemption from FATCA
l
disregarded from the owner unless the owner of the LLC is another LLC that is not
Other Govt
reporting code (if any):
disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC
other (specify)
that is disregarded from the owner should check the appropriate box for the tax classification
`
of its owner.
Newspaper
Under penalties of perjury, I certify that:
p
1. The number shown on this form is my correct taxpayer identification number (or I am waiting fora number to be issued to me), and
MOO i
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service
(IRS) that I am subject to backup withholding because of a failure to report all interest or dividends, or {c}the IRS has notified me that I am no conger
subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined later in general instructions), and
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4. The FATCA code(s) entered on this form if an indicting that i am exempt from FATCA reporting is correct.
( Y) � g p p g
Certification instructions: Please refer to the IRS Form W-9 located on the IRS Website fhttps://www.irs.xovL}:
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*Printed Name:
Kealey Stortz
*Printed Title: Applications Specialist
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Authorized U.S.
* Date:
t"'
signature:
10/15/2018
Please complete the "Modification to Existing v Ndor Recordst' Section below if there have been any changes to the following: Tax identification Number (TIN),
Legal Name, Business Name, Remittance Addres
Return to the NC State Agency from which you are requesting payment.