NCGNE0942 Rescission Request

FOR AGENCY LJS QNLY
+ Division of Energy, Mineral & Land Resources Date Received
�f Land Quality Section/Stormwater Permitting Program Year Month Day
NCDENRNational Pollutant Discharge Elimination System 1
NRCNM CAROLINA DEFNATURAL
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ENVIRONMENT nxo NpiURAL RESIXIRCES
RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I N C G I N I E 0 9 1 4 1 2
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name National Express LLC
Facility Contact Betty Jurkowski
Street Address 2601 Navistar rive
City Lisle State IL
County Dupage E-mail Address
Telephone No. 630 821-9058 Fax:
ZIP Code 60532
[e-mail]
3) Reason for rescission request (This is ree u„ired information. Attach separate sheet if necessary):
0 Facility closed or is closing on. 2/28/2018 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.
Signature &Z
Betty Jurkov6vl
Print or type name of person signing above
Date 3/9/2018
Sr. Environmental Compliance Manager
Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612 REFCEIV
ED
1612 Mail Service Center, Raleigh, Norih Carolina 27699-1612 M
Phone: [phone] FAX: [phone] AR 2 �aiB
An Equal Opportunity 1 Affirmative Action Employer $TOR ���TE, U QUAL]
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