NCG060291 Rescission Form

NCDENR
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year Month Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. 'VY� V
1) Enter the permit number to which this request applies: til�q, �9N0
Individual Permit (or) Certificate of Coverage �Tc�,Qp�
N C S N C G (0 0 2 4f%
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2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Na
Facility Contact
Street Address
City
County
Telephone No.
ZO3 S . :Rk1 t_ QpP't -s'7
W % CQp State W, ZIP Code 24SS5
SaF}NSiCi E-mail Address SPaM.1f ��(II��tRIF�OT(?-0L P.C�k�1
910 Zq3-�54� Fax: q 10 Zq3- 3lo(Ac
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on . All industrial activities have ceased such that no discharges of
s ormwater are contaminated by exposure to industrial activities or materials.
Ll��/Facility sold to jM;LrO r1&yj Pnc�`f . 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 Date `C) lao�1
Print or type name of person signing above 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
1612 Mail Service Center, Raleigh, North Carolina 27699-1612 1�
Phone: [phone] FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer
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