NCG050159_Rescission_20191003

Environmental
Quality
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Dat© Received
Year
Month
ay
RFr,FIV"-D
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permi .
UE'vIR-LAND QUALITY
1) Enter the permit number to which this request applies: ` '011RMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N I C I U I I I N I C I G 05 I D I I JI��
2) Owner/Facility Information: " Final correspondence will be mailed to the address noted below
Owner/Facility Name Kroy Building Products- Fair Bluff
Facility Contact Terry Bass
Street Address 303 W. Maior
City Kearney State MO ZIP Code 64060
County Clay E-mail Address [e-mail]
Telephone No. 816-536-9605 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet If necessary):
5?f Facility closed or is closing on 9/28/2019. 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, Somplete and accurate.
A—
Date ?/27�/f
arN4- ,2�nAaew
Print or 4pe nam of person signing above Title
Please return this completed rescission request form to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 20183an10