NCG100206_Rescission Request_20210602

FOR AGENCY USE ONLY
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Assigned to: tik.IVW
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RECEIVED
Division of Energy,Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System JUN 02 2021
Rescission Request Form DENR-LAND QUALITY
STORMWATER PERMITTING
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
Directions. Print or type ail 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 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 permit correspondence will be mailed):
Name of legal organizational entity: Le ally responsible person as signed in Item(4)below:
C.�rct�niJ Pd�r#1 LLC It/responsible
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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(facility requesting rescission):
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Street addres �
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City-:{ _ ,, State: ZipCode: County:. `
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Permit Number to which this request applies: A , ^ I00 0r_
3. Reason for rescission Request �[J
This is required information.Attach separate sheets if necessary.
Facility is dosed 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: closed dr sj)Ned 1008
©Facility sold.
Sold to:
On date:
D Other(please explain):

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 indude a fine not
to exceed ten thousand dollars($10,000).I 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:-Jo kv w a,l/� (_ o Hoe)
�Title: OLnQ, 7
5/27/
gnature of Applicant) (Date igned)
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh,NC 27699-1612
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