NCG080392_Rescission Request_20201013

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
EnvironmentalaFOR APPRQ�/�
RESCISSION REQUEST FORM IPAyiw
ar
OCT
Please fill out and return this form if you no longer need to maintain your NPDES stormwa permit. � '-',r,;(1
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C s N 0 0 0 8 0 3 9 2
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name Averitt Express Greensboro Service Center
Facility Contact John Walton
Street Address 8814 West Market Street
City Colfax State NC ZIP Code 27235
County Guilford E-mail Address [e-mail]
Telephone No. (931) 520-5059 Fax: (931) 520-5699
3) Reason for rescission request(This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on /2 /)° 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 a familiar with the information contained in this request and to the best of my knowledge and belief
such information ' ue, complete,nd accurate.
Signature ��j,vim_ Date /04 /e2a'l`°
Barry Blakely ` V.P.Operations
Print or type name of person signing above Title
Please return this completed rescission request form to: DEMLR- Stormwater ProgramA E C E I V E D
Dept. of Environmental Qualitg
1612 Mail Service Center OCT 71170
Raleigh, North Carolina 27699-161
DENR-LAND QUALITY
STORMWATER PERMITTING
Revised 20183an10