NCGNE1118_COMPLETE FILE - HISTORICAL_20170217

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
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DOC TYPE
❑COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
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YYYYMMDD

k'� • Division of Energy, Mineral & Land Resources
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r.�..� Land Quality Section/Stormwater Permitting Program
NCDENRNational Pollutant Discharge Elimination System
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RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
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 N I C I G I N I E I 1 I 1 1 8
2) Owner/Facility Information: " Final correspondence will be mailed to the address noted below
Owner/Facility Name JELD-WEN Inc (Leased "Trinity "Transport Warehouse, 317 Green Needles Dr., Lexington, NC)
Facility Contact Chad Thiel, Plant Manager
Street Address 647 Hargrave Rd Suite D
City Lexington State NC ZIP Code 27292
County Davidson E-mail Address CThiel a JELDWEN.com
Telephone No. 336 - 956 - 1 105 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on f02/13/2017 All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to
on f 1 . 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:
DS R-LA M) QUALITY
1, as an authorized representative, hereby request rescission of�covetaQe7underithe; NFDES 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, om lete and accurate.
Signature Date ° // 741 1
Chad Thiel
Print or type name of person signing above
Please return this completed rescission request form to
Plant Manager
Title
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
Phone: [phone] I FAX [phone]
An Equal Opportunity l Affirmative Action Employer