NCG080790_Rescission Request_20210825

FOR AGENCY USE ONLY
Division of Energy,Mineral& Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
• IN
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM JU0 25 LW'
;iENR4 A QU/,►IT r
Please fill out and return this form if you no longer need to maintain your NPDES stormwater p6r tMWA?ERPERMllTtNr3
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C S N C G 0 8 0 7 9 0
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name Rolling Frito-Lay Sales/Whiteville Bin
Facility Contact Rob Sapienza
Street Address 2700 Nevada Blvd.
City Charlotte State NC ZIP Code 28273
County Mecklenburg E-mail Address [e-mail]
Telephone No. 704 927-7377 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 3/6/20215. 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 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.
SignatureDate
Z�\1
Rob Sapienza Regional Fleet Manager
Print or type name of person signing above Title
Please return this completed rescission request form to: DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 20183an10