NCG080284_Rescission Request_20191029

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
Date Received
Year
Month
Da
REr,F:,I @/Fl_d
OCT 2 9 2019
Please fill out and return this form if you no longer need to maintain your NPDES stormwater p@@ ft.LAND QUALITY
STORMWATER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S N I C I G 45 1 g 0 2 8
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Ck4r to`Pp— 0bse, rtrcr T'aIJ5P02TAJ-( o10
Facility Contact tc_t Cr- "10 (,C--,-
Street Address 1001 Pres.s/?=y G
City
County ill e�nk--I.e su &
Telephone No. -1 DC- S 72.,- 07Ll 7
State NC:- ZIP Code 2.T2-1 -7
E-mail Address I^Y�lbl�l�e✓'lo phSC✓>r, (;OM
Fax:
3) Reason for rescission request (This is reguired 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.
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 % A 5 /( -7
R-I c.- 124 le- `rrQtJe P&A;rWT70J MaN466'e
Print or type name 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 2018Jan10