NCG210022_Rescission Request_20190624

Division of Energy, Mineral &Land Resources
Land Quality Section/Stormwater Permitting Program
NZ-0 National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Reoai.d
Year Nonni Da
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 N C G 'a 10 a
2) Owner/Facility Information: •Final correadandence will be mailed to the address noted below
Owner/Facility Name I.t•JohylSO
Facility Contact i;l '
Street Address 13 I rCB!A Sz f 3
City K2nn {'_.Qti,�t State
County E-mai
Telephone No. Fax:
ZIP
3) Reason for rescission request (This is reaultred 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 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.
0 other 1Qd2Pgph 0%SSO�VIcQ �Y1 12 I1� I 1 %
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 tr. , cote.
Signature Date aZ
4�Tr4.JaltwSA Sr .
Print or type name of person signing above Title
Please return this Completed rescission request form to:
Revised 20181an10
DEMLR - Stormwater Program
Dept of Environmental Quality
1612 Mail Servlce Center
Raleigh, North Carolina 27699-1612

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENTAL QUALITY
INVOICE
Annual Permit Fee
LIM`1%
(IIIII IIIII IIIII IIIII IIIIIII IIIII III IIIII IIIII IIIII IIIII IIIII IIII IIII
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 parmit 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. 2019PR004846
Annual Fee Period:
2019-07-01 to 2020-06-30
Permit Number: NCG210022
Johnston County
Invoice Date:
06/04nO19
TEJa nso0 er Co -
— D.Date:
07/94n019 -
TE Johnson
Annual Fee:
$100.00
T E Johnson Lumber Cc
PO Box 341
Benson, NC 27504
1. You may pry either by mail with check/money order QR by electronic Payment(eCheck or Credit Card).
2. If payment is by checlumoney order, please remit payment to:
NCDE _ .aion of Ene Mineral and Land Resources
Ask. Stormwatereeli
512 N. Salisbury Street
1612 Mail Service Center
Raleigh. NO 27699-1612
3. If payment is electronic, please see h=:fideg.ng.govlepaymentsistormmt. to pay electronically. Payments by eCheck will
debt your checking accoum. 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 25M12.
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 Wood the Annual Administering and Compliance Fee
Coordinator at 919-707-9220.
(Return This Portion With Check.)
II I I� IV6 II �IIII IIIII III IIIII IIIII IIIII IIIII IIIII IIII IIII
* ANNUAL PERMIT INVOICE 2 0 1 9 P R 0 0 4 8 4 6+
Open
Invoice Number: 2019PR004846 Annual Fee Period 2019-07-01 to 2020-0"0
Perm it IN um bar: NCG210022
Johnston County Invoice Date: 6/4/2019
T E Johnson Lumber Co Oue Date: 7/4/2019
Annual Fee: $100.00
T E Johnson
T E Johnson Lumber CD
PO Box 341 Check Number:
Benson, NO 275W