NCG070063 Rescission Request

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Mont€, Day
National Pollutant Discharge Elimination System
Environmental
Quality
RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES storm, --,zrmit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C S N C G o 7 Q
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name
Facility Contact
Street Address
City
County
Telephone No.
<1
C.
.• ,i I If•. ;
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
[Facility closed or is closing on aQltp . All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to
'Id
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.
Signature
Print or type/name of person signing above
Please return this completed rescission request form to
RECEIVED
APR 17 2018
DENRUND OLIALR Y
Revised 2018Jan10 8T0AM kXR PERMITTING
JJDate /3
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Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612