NCS000536_Rescission Request_20210414

FOR AGENCY USE ONLY
Date Received:
RECEIVED
Division of Energy, Mineral, and Land Resources Land Quality Section
ITY
National Pollutant Discharge Elimination System gENWATER OVAl ITT
Si'pRMWATER PERMITTING
ING
Rescission Request Form
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
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.
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:
Floorazzo Tile LLC
John Sich
Street address:
City:
State and zip code:
INC
1217 Harold Andrews Road
Siler City
27344
Telephone number:
Email address:
336-302-5737
[e-mail]
2. Industrial Facility (facility requesting rescission):
Facility name:
Floorazzo Tile LLC
Street address:
215 West third Street
City:
State:
Zip Code:
�27344
County:
Siler CityNC
Chatham
Permit Number to which this request applies:
Unknown. The only copy we had was distro ed in a flood.
3. Reason for rescission Request
i ms is reauirea inrormauon. Httacn separate sneers n
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:
fl Facility sold.
Sold to: Leased Facility and we moved out of on 3-1-2021
On date:
()Other (please explain):
We stopped applying for a permit in 2015 when we dis a $75,000 capital expenditure and stopped discharging dirty water

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.
Un_Oer penalty of law, I certify that:
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: John Sich
Title: owner
921''V3 &eA 4-4-2021
(Sig ffifture of Applicant) (Date Signed)
Mdil Lhe entire package tu: DEMLR—SLurrnwater Prugrarn
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC27699-1612
Page 2 of 2