NCG170054_Rescission Request_20200116

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
NZ National Pollutant Discharge Elimination System
Environment,
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
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 S I I I I I I N I C I G 11 17 10 10 15 4
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Hanes Geo Components
Facility Contact
Street Address
City
County
Telephone No.
Dylan Shook
405 W B Street
Butner
Granville
828 502-3253
State NC
E-mail Address
Fax:
ZIP Code 27509
[e-mail]
3) Reason for rescission request (This is rectuired information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 01/2012. 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:
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 — LI
rJ
Dylan Shook
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 2018Jan10
Date 1-16-2020
Environmental Manager
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612