NCG140455_Rescission Request_20211122

I
KtuClv1=Ld
FOR AGENCY USE ONLY
Assigned to: 13• l
ARO FRO MR RRO WARO WIRO WSRO
vT1 18 2021
DENR-LAND QUALITY
TORMYJATER 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 permit correspondence will be mailed)
e of legal organizational entity: Legally respom
Stuart Stever
venson-Weir
FStreetaddress: City'
Hillphone
3 S. Anderson RoadRock
number:JEmail address:
-324-4455 Stuartswsc
2. Industrial Facility (tacwty requesting reb-b-11r.
Facility name:
Stevenson -Weir Chadotte
Street address:
3725 We Blvd
State: Zip Code:
City: 28273
Charlotte NC
Permit Number to which this request applies:
NCG140455
3- Reason for rescission Request
person as signed in Item (4) below:
State and zip code:
SC 29730
County:
This is required information. Attach separate sheets if necessary.
0 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: May 2018
® Facility sold.
Sold to:
On date:
OOther (please explain):

I
4. Applicant Certification:
North Carolina General Statute 143-215.68 (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: Shannon S. Houck
Title: Environmental for Stevenson -Weir
o� a"
(Signature of Applicant)
11/9/2021
(Date Signed)
Mail the entire package to: DEMLR— Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 2 of 2