NCG080685_Rescission Form_20180507

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
I Month
I Da
familiar with
the information contained
in this request and to the best of my knowledge and belief
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)
N C S
Certificate of Coverage
N O G G r (J l2 E `a
2) OWner�Fecility InformatlOn: 'Final correspondence will6e mailed to the address noted below
Owner/Facility Name NEw Hanover County Wave Bus Depot -Castle S
Albert Eby
treet
Facility Contact
Street Address
City
County
Telephone No.
1110 Castle Street (permit address)
Wilmington State NC
New Hanover E-mail Address
910 343-8717 rnv, 910
ZIP Code 28405
3438317
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 2/2015 .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: This porperty is owned by the City of Wilmington. We have since built and moved into a new Facility.This facilty has its
own permit. We moved from this property in 2015
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 '�� Date d 51 a 41 Zo I ti
Print or type name of person signing above Title
Please return this completed
rescission request form to:
Revised 2018]an10
DEMUR -Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612