NCG170135 Rescission Request_20190805

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
0jinlify RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Morrth
Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I 1 -j p j 13� N I C I G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name C-oplancl LdUStrl�'S , nC,
Facility Contact
Street Address
City
County
Telephone No.
3 3 co A X tc - 0 9, % a. Fax:
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
. (04
on . If the facility will continue operations under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
❑ Other:
4) Certification:
I, as an authorized representative, hereby request rescission 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.
ISignature �� DQ ` Date—� I
i m�S . C�I �� �'a� too
Print or type name of person signing above Title
Please return this completed rescission request form to: DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
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Revised 2018Jan10 I

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENTAL QUALITY
INVOICE
Annual Permit Fee
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: 2019PR006034
Permit Number: NCG170135 .
Alamance County
Copland Industries Incorporated
Mark Andrews
Copland Industries Inc
PO Box 1208
Burlington, NC 27216
Annual Fee Period: 2019-08-01 to 2020-07-31
Invoice Date: 07/02/2019
Due Date: 08/0112019
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/money 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:l/deg.nc.gov/epayments/stormwater to 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)
ANNUAL PERMIT INVOICE
Invoice Number: 2019PR006034
Permit Number: NCG170135
Alamance County
Copland Industries Incorporated
Mark Andrews
Copland Industries Inc
PO Box 1208
Burlington, NC 27216
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Open
Annual Fee Period: 2019-08-01 to 2020-07-31
Invoice Date: 7/2/2019
Due Date: 8/1/2019
Annual Fee: $100.00
Check Number: