NCG030129_Rescission Request JandJ Machine Works_20190213

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
Month
Day
RECF. I ED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater P912MLAND QUALITY
STORMWATER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I I N C G () ,3 0 Z
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name L(J0 -3
tr_Rk
Facility Contact C_Jg `L e3 %(fie ()
Street Address
City v . r
County —hAL) i�
Telephone No. .336 "ems
State IV6 ZIP Code
E-mail Address
Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
— 0 t)1,6
Facility closed or is closing on 01 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:
f, E�s an a uthr`rize-+ renrescntative 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 beiier
such information is true, comple7d',a,rate.
Signature � Date
Print or typ name of person signing above Title
Please return this completed rescission request form to
Revised 2018Jan10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612