NCGNE1246_Rescission Request_20200625

FOR AGENCY USE ONLY
Division of Energy,Mineral& Land Resources Date Received
Year Month Day
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
J � 2 5 2020
1) Enter the permit number to which this request applies:
Individual Permit (or) a Certificate of Coverage
DENR-LAND�� QUALITY
g STORMWATE PERMITTING
N C S N C GN E 1 2 4 6 J
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name E_J.Victor, Inc.
Facility Contact Terrie Peeler
Street Address 1020 N. Green Street
City Morganton State NC ZIP Code 28655
County Burke E-mail Address [e-mail]
Telephone No. 828 437-1991 — Fax: 828 438-0744
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.
Q Other: Lease expired 12/31/19&was not renewed. Operations were moved to other property located at
110 Wamsutta Mill Road, Morganton, NC 28655
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 �Zt� / l• � Date 06/23/2020
Terrie N. Peeler Human Resources Manager
Print or type name of person signing above Title
Please return this completed rescission request form to: DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10