NCG060068_Rescission Request_20190305

Environmental
Quality
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RFSCISSION RFOLIFST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
P1=r,rI\,
MAR o 5 2019
Please fill out and return this form if you no longer need to maintain your NPDES stormy+ �il��t�il.QIJALITy
i AT Ell FEF2Ml i i ING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S N I C I G e�
POT-
2) Owner/Facility Information: * Final
()WIWI/FdOlily Name
FdLilily CuiilaU r/ / `j.-�,
Street Address Z1
City Z'_
County C' C
Telephone No.
pondence will be mgiled to the address noted below
fi
�_)/) -, 5 J l �_ .
State [I 1 C_ ZIP
�J E-mail Address]
4�-e�—O d- Fax:
/Y
rS , 4 t— Le C6/iyifttG�
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
Facility closed or is closing on . All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to T ' , Z' Z � on . If the facility will continue operations under the new owner it
may be more appropriate to request an ownership chipnge to reissue to permit to the new owner.
Other: ()/��l /U �s r Lb C1
4) Certification:
1, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
subject facility. 1 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.
Signature
Print or type name of person signing above
Date
Title
Please return this completed rescission request form to: DEMLR - Stormwater Program
oxe'41S Dept. of Environmental Quality
. 1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10

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NORTH CAROLINA DEPARTMENT OF
ENVIRONMENTAL QUALITY
INVOICE
Annual Permit Fee
6 dZ604 1z
.2019o.000944.
Open
This annual fee is required by the North Carolina Administrative Code. It covers the administrative 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 later decide a permit is
needed, you must reapply, with the understanding the permit request may be denied due to changes in environmental,
regulatory, or modeling conditions.
Invoice Number: 2019PR000944
Permit Number: NCGO60068
Mec:klelIbUrg Cauniy
B & H Fuods hiuurporulod
Stanley G. Bracey
B & H Foods Inc
2122 Thrift Rd
Charlotte, NC 28208
Annual Fee Period: 2019-03-01 to 2020-02-28
Invoice Date: 02/05/2019
Duo Data 03/07/2010
Annual Fee: $100.00
Notes:
1. You may pay either by mail with check/money order OR by electronic payment (eCheck or Credit Card).
2. If payment Is by check/rnoney order, please remit payment 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. If payment is electronic, please see https:/Ideg.nc.gov/epayments/stormwaterto pay electronically. Payments by eCheck will
debit your checking account. Credit card transactions will incur a convenience fee.
4. Please include your Permit Number and Invoice Number on all correspondence.
5. A $25.00 processing fee will be charged for returned checks in accordance with North Carolina General Statute 25-3-512.
6. Non -Payment of this fee by the payment due date will initiate the permit revocation process.
7. Should you have any questions regarding this invoice, please contact the Annual Administering and Compliance Fee
Coordinator at 919-707-9220.
(Return This Portion With Check)
.201 9oae00444ANNUAL PERMIT INVOICE
Open
Invoice Number: 2019PR000944
Permit Number: NCG060068
Mecklenburg County
B & H Foods Incorporated
Stanley C. Bracey
B & H Foods Inc
2122 Thrift Rd
Charlotte, NC 28208
Annual Fee Period: 2019-03-01 to 2020-02-28
invoice Date: 2/5/2019
Due Date: 3/7/2019
Annual Fee: $100.00
Check Number: