NCGNE0644_Rescission Request_20181204

Division of Energy,Mineral& Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System FOR AGENCY USE ONLY
Environmental
Quality RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. r^r 14 20 tl3
1) Enter the permit number to which this request applies: DENR-LAND QUALITY
Individual Permit (or) Certificate of Coverage STORMWATER PERMITTING
N C S N C G 0 b 4 4
2) Owner/Facility Information: *Final correspondencee will be mailed to the address noted below
Owner/Facility Name C O y1 Sd` �N(�c( -f f V`e -co ��Q , Set- Se Ea_C t
NUM
Facility Contact U N -itA'tl 0
Street Address (n3I N A v'enu.P_
City NW State NC_ ZIP Code D.-1110
County h t 0() E-mail Address
Telephone No. `1C,k4 22 I 1 1,f3 0 Fax:
3) Reason for rescission request(This is required information. Attach separate sheet if necessary):
D—F'acility closed or is closing on 11 1 1 I 1 T . 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 Date
12LI iq
A-daWI 14-0-14/1 i ✓1 H{}S AftolT
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 20183an10

IC Division of Energy,Mineral& Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System FOR AGENCY USE ONLY
Environmental
Quality RESCISSION REQUEST FORM
RPCPI\QED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. DEC 14 NO
1) Enter the permit number to which this request applies: DENR-LAND QUALITY
Individual Permit (or) Certificate of Coverage STORMWATER PERMITTING
N C S N C G N C Q E & L4
2) Owner/Facility Information: *Final correspondencewill be mailed to the address noted below
b eo r
Owner/Facility Name S 't cl Me-A-re) / 1 AG y lk) 6, ([,�.1,,e ��-t 1,T'
Facility Contact A0L0.' 1 l-0.Ntii 1 n
Street Address `2.—f 0ct �)a_d ky f AVQA
City PI On rt Q State NC" ZIP Code 211(0
County (�A t ci-n E-mail Address
Telephone No. 'log 2Z,\ 1 Ll3 C) Fax:
3) Reason for rescission request (This is`required information. Attach separate sheet if necessary):
1''Facility closed or is closing on �,1.I. 11 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 Date
Ada I)a,lvi_i A Ln t.c MI r
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