NCG030633_Dellner Inc Permit Rescission Form_20190308

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
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
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

2)Owner/Facility Information:* Final correspondence will be mailed to the address noted below
Owner/Facility Name ______________________________________________________________________
Facility Contact ______________________________________________________________________
Street Address ______________________________________________________________________
City _______________________________ State _______ ZIP Code _________________
County _______________________________ E-mail Address ________________________
Telephone No._______ _______________________ Fax: ________ ________________________
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
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 Date
Print or type name of person signing above Title
Please return this completed rescission request form to:
N C S N C G
Revised 2018Jan10