NCG130074 Rescission Request

NCDENR
NORTH C�OL— DEPARTMENT or
ENVIRONMENT — Na URAL RL URGE5
Division of Energy, Mineral & Land Resources
Land Quality Section/Storrnwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year I Month F Day
JUN 0 6 Inv
Please FII out and return this form if you no longer need to maintain your NPDES stormwater peGWOR WATeRPQUMIT
1) Enter the permit number to which this request applies:
TING
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I I N I C. I G 1 3 1 0 1 0 1 7 1 4
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Raleigh Reclamation, LLC
Facility Contact
Street Address
City
County
Telephone No.
Lee Strickland
520 Pristine Water Drive
Apex
Wake
919-825-1699
State NC ZIP Code 27539
F -mail Address [e-mail]
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 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.
f� Other. Facility has been leased to another company
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.
Signature641
Date
Print or type name of person signing above Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
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