NCG170026_Rescission Request_20191028

Environmental
Quality
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
PA�!C
Please fill out and return this form if you no longer need to maintain your NPDES stormwater pit. 1-1
CD — I
249
1) Enter the permit number to which this request applies: M ��Ty
Individual Permit (or) Certificate of Coverage SgFF�FcTjCA
N I C I S N I C I G 7 D D a to
2) Owner/Facility Information: * Final correspondence will be mailed to the addressnotedbelow
Owner/Facility Name rQ b Z'nd O54;-1 es - 1 nCl
Facility Contact /" i o_ Jr" a n
- Street Address 141 R q:� I /� pn .4
City L i'ri ca )`�-D n State /V a ZIP Code
County Lincoln E-mail Address Ciebr-aclar'c�¢V�
Telephone No. b` '735-D573 Fax: 7a`+ _135- 2610 C orn
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. .
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
l�
Print or type name of person signing above
Please return this completed rescission request form to:
Date 9
�on fro /ler
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 20183an10