NCG020423_Rescission Request_20240620

FOR AGENCY USE ONLY
Assigned to: /I
ARO F O MRO FRO WARO WIRO WSRO FCeikFo✓U�
Division of Energy, Mineral, and Land Resources Land Quality Section Ig1p1�
National Pollutant Discharge Elimination System
Rescission Request Form
Please f(ll out and return this form if you no longer need to maintain your NPDES stormwater permit.
Dir s: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
$ 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:
AD l\jt L- Soot
q State and zi c
street . 20 0 .t eV\ v� 1'11 01*6 ty IL M/, 6�� lG
Teleph'pne nu r: Email address:
b 6�3 0 l �6 - `Q
2. Industrial Facility(facility requesting resdssion):
FacilitN name:
stye dress au Ij 1 A statie/ �, .Z' o ! / `I Al, UV
Permit Number to which th' request p li s: Z
AZ
3. Reason for rescission Request
This is required information.Attach separate sheets if necessary.
acifty is closed or closing.All industrial activities have ceased such that no discharges of stormwater are contaminated
t{y exposure to industrial activities or materials.
Date closed/closing:
0 Fadlity sold.
Sold to:
On date:
r(please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.68(i)provides that: Any person who knowingly makes any false statement,
represen tion,or certification in any application,record,report,plan,or other document filed or required to be maintained
under thi Article or a rule implementing this Article...shall be guilty of a Class 2 misdemeanor which may include a fine not
to exoeec ten thousand dollars($10,000).1 hereby request exclusion from NPDES stormwater permitting.
Under pe natty of law,1 certify that:
O I,as an authorized representative,hereby request recission of coverage under the NPDES storrnwater Permit for the
subject facility.I am familiar with the information contained in this request and to the best of my knowledge and belief
information is true,complete,and accurate.
Printed f lam of Person Signing:
Title:
(Slgnatu a of Applicant) (Date Signed)
Mail entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
-a,
Page 2 of 2

FOR AGENCY USE ONLY
Assigned to:
ARO FRO MRO RRO WARO WIRO WSRO
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, 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 prganizational entity: ally responsible person as si ned in Item (4)below:
AQ�t 4 I l,� IN6S L-Cnn,,:,,l�'R/�RP ) / bLI) L. b 3�
Lreet OZUeJo 'Ut) 4v5 6�/laddr� 67aV p oa�3
Tel glhone number- E na6_" ts: ZO117.7
2. Industrial Facility (facilitVrOtIbesting rescission):
Facility nameS:
l � ✓V11N
SLel3C] �XA IZOA0
City: W� State: Zip C my
;zx, /Y C 2ivKw�f2
Permit Number to which this request applies:
3. Reason for rescission Request
This ' required information. Attach separate sheets if necessary.
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: dl
®Facility sold.
Sold to:
On date:
[3Other(please explain):

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.
U er 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: Arz VOL1J L, SD(3p�L
Title: 4AMM6&-?Z M AN' '-/� ARF/4
aos Sowl{ Cf u2ck ll p2tV' U;I W1)V6-b1V)IBC ��yD
(Signature of Applicant) (Date Signed)
Mail the entire package to: DEMLR Stormwater Program
16__ ail ,.:. meter :, � ,�,,• ,�
Raleigh, NC7599 1612
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