NCG080266 Rescission Request

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FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Da
National Pollutant Discharge Elimination System
Environmental
Quality 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 I I I N I C I G 10 18 10 12 6 6
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name H&W TRUCKING CO.INC
Facility Contact GARY HAROLD
Street Address 1772 N ANDY GRIFFITH PARKWAY
City MOUNT AIRY State NC ZIP Code 27030
County SURRY E-mail Address [e-mail]
Telephone No. 336-789-2188 Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 12-1-17 . 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 informat(pn is true, complete and accurate.
MW
Aug. 9, 2018�= =�� ✓Date
Gary Harold President
Print or type name of person signing above Title
Please return this completed rescission request form to:
Revised 20183an10
DEMLR - Stormwater Program �^
Dept. of Environmental Quality (1�
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1612 Mail Service Center Off. , j l�
Raleigh, North Carolina 27699-16120%'%%0?0>,e
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