NCG020802_Rescission Request_20210330

FOR AGENCY USE ONLY
Date Received:
Division of Energy, Mineral, and Land Resources Land Quality SectioOQ '
National Pollutant Discharge Elimination System
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Rescission Request Form 144/0
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Please fill out and return this form if you no longer need to maintain your NPDES storm water permit.��/%y�,�
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Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program,1612 Mail Service Center, Raleigh, NC 27699-1612. The submission of this form does not
guarantee exclusion from NPDES stormwater permitting. Prior to exclusion from NPDES stormwater permitting a
site inspection will be conducted.
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1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
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Street address:
City:
State and zip code:
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Telephone number:
Email address:
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2. Industrial Facility (facilitV requesting rescission):
Facility name:
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Street address:
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City:
State:
Zip Code:
County:
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Permit Number to which this request applies:
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3. Reason for rescission Request
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Q Facility is closed or closing. All industrial activities have ceased such that no discharges of stormwater are contaminated
by exposure to industrial activities or materials.
Date closed/closing:
Facility sold.
Sold to: &k eoc(oTk�l LA}I)b L.LI'
On date: ill 3 (a.o.->o
()Other (please explain):
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MA RP.2021
DENR•LAND OUALITY
STORMWATER PERMITTING

4. Applicant Certification:
North Carolina General Statute 143-215.6E (i) provides that: Any person who knowingly makes any false statement,
representation, or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
ill I, as an authorized representative, hereby request recission 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.
Printed Name of Person Signing: MAP—T; Q
Title: M'gK)ftCri 4
(Signature of Applicant) (Date Signed)
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612`Mail Service Center
Raleigh, NC 27699-1612
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