NCG060338_Rescission Request_20210517

FOR AGENCY USE ONLY
NCG
Assigned to:
ARO FRO MRO WARO WIRO WSRO
MAY 17 2021
DENR-LAND QUALI TY
STORMWAI ER PERMITTING
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
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, INC 27699-1612. The submission of this form does not
guarantee recission of your NPDES stormwater permit. Prior to the recission of your NPDES stormwater permit, a
site inspection will be conducted.
1. Owner/Operator (to whom all Dermit correspondence will be mailed):
Name of legal organizational entity:
L L C
Legally responsible person as signed in Item (4) below:
(A
b are--)
Street addres •
Qb As? owi�
City:
5(16VJ NCI(
State and zip code:
c. ak
Telephone numberY
Email address:
ras
2. Industrial Facility (facility requesting n
Facility name: toukk CiV
Street address: f t
City: I State�Q
Permit Number to which this request apl
3. Reason for rescission Request
11113 n ICLjU II CU Ill) U 1 IIIQLI VII. /'1 LLQLII Z)UPCI1 QLc JI ICC LJ II IICL.CJJOI Y.
El 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:
Ef Facility sold. nwe ��Al �s. �ryU2SdYYl�
Sold to: lam' V'1 (1-O On date: l�r/� o1-Q , da I
0 Other (please explain)

4. Applicant Certification:
North Carolina General Statute 143-215.66 (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:
❑ 1, 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
Title: oW nor
6 1---
(Signature f Applicant)
l 0&' G. 14 an
5. 1 3-aoa I
(Date Signed)
Mail the entire package to: DEMLR — Stormwater Program
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