NCS000359 Rescission Form

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month 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 stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I SO 10 10 13 1 1 N I C I G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Auria Old Fort
Facility Contact Stephanie Boggs or Kenny Greene
Street Address 1506 East Main Street, PO Box 669
City Old Fort State NC ZIP Code 28762
County McDowell E-mail Address [e-mail]
Telephone No. 828 668-3436 Fax: [phone]
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.
❑✓ Other" Permit was for an offsite landfill that is now closed and following a closure plan.
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 J. ' I lt..l I !.1
Stephanie Boggs
Print or type name of person signing above
Please return this completed rescission request form to
RECEIVED
JUN 25 2018
DENR-LAND QUALITY
STORMWATER PERMITTING
Revised 20183an10
Date 06/19/2018
EHS(Training Coordinator
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Vt