NCG030713_Rescission Request_20201104

Division of Energy,Mineral&Land Resources Date Received
BIZ Year Month Day
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System FOR AGENCY USE ONLY
Environmental
Quality RESCISSION REQUEST FORM
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 c S 0 3 0 7 1 3 N 0 0 0 3 0 0 0 0
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name Banner Service Corporation
Facility Contact Chris Roeder, General Manager
Street Address 6424 South Blvd
City Charlotte State NC ZIP Code 28217
County MECKLENBURG E-mail Address CROEDERBARGRIND.COM
Telephone No. 440 670-8303 Fax: 440 572-2436
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 08/21/20. 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.
❑ Other:
RFCPR/Fn
4) Certification: NOV 04 2020
DENR-LAND QUALITY
I, as an authorized representative, hereby request rescission of coverage under the NPDESCabiftib&Pfiiivitiffirtir 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.
Signature Date 10/30/2020
CHRISTOPHER A. ROEDER GENERAL MANAGER
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
Revised 2018Jan10