NCG020301_COMPLETE FILE - HISTORICAL_20170306

STORMWATER DIVISION CODING SHEET
RESCISSIONS
PERMIT NO.
DOCiYPE
❑COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
❑ aOl q DE U
YYYYMMDD

Energy, Mineral &
Land Resources
ENVIRONMENTAL QUALITY
Mr. Sam W. Smith, Jr.
Sam W. Smith, Inc.
P.O. Box 428
Eden, N.C. 27289-0428
Dear Mr. Smith:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
TRACY DAVIS
Director
March3, 2017 RECEIVED
MAR 06 201
CENTRAL FILES
0WR SECTION
Subject: Rescission of NPDES Stormwater Permit
Certificate of Coverage Number NCG020301
Rockingham County
On December 22, 2016, the Division of Energy, Mineral and Land Resources received your
request to rescind your coverage under Certificate of Coverage Number NCG020301. In
accordance with your request, Certificate of Coverage Number NCGO020301 is rescinded
effective immediately.
Operating a treatment facility, discharging wastewater or discharging specific types of
stormwater to waters of the State without valid coverage under an NPDES permit is against
federal and state laws and could result in fines. If something changes and your facility would
again require stormwater or wastewater discharge permit coverage, you should notify this office
immediately. We will be happy to assist you in assuring the proper permit coverage.
If the facility is in the process of being sold, you will be performing a public service if you would
inform the new or prospective owners of their potential need for NPDES permit coverage.
If you have questions about this matter, please contact us at 919-707-9200, or the Stormwater
staff in our Winston-Salem Regional Office [phone].
cc: Winston-Salem Regional Office
Stormwater Permitting Program
Central Files - w/attachments
Sincerely,
�r
for Tracy . Davis, PE, CPM, Director
Division of Energy, Mineral and Land Resources
Nothing Compares--,_,—
State of North Carolina I Environmental Quality Energy. Mineral and Land Resources
512 N. Salisbury Street 1 1612 Mail Service Center Raleigh, North Carolina 27699-1612
919 707 9200

10
NC®ENR
NORTH CAPOL4 DEPIPT- OF
C_.0.ME.T pup N .I .A RE9"U CE9
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY 115E ONLY
Date Received
Year
Month
Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
�cr�r; -fA; ,b Oi
1) Enter the permit number to which this request applies: �r�% MVVA��F PEP,-, f��
Individual Permit (orj Certificate of Coverage
N C S N C G Q Q Q
2) Owner/Facility Information: * Final correspondence will be rnailed to the address noted below
Owner/Faciiity Name Sa�g I.t9, `�—k �h G• _-.__
Facility Contact
Street Address
City
County
Telephone No.
r�- , U C � r-i G �lfl�„ -- - --
�3G r1 3-q fS/
State
E-mail Address
Fax: 3 5&,
ZIP Code 7ra,'S?- ell Z5"
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
[Facility closed or is closing on sr` 3� All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
[OFacility sold to I 't B QS on I'7L!/ . 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.
I�] 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 reauest and to the best of my knowledge and belief
such information is true, complete and accurate.
Signature „� Gv, i //?�� �R�r Y� Date l— ITf le, 14
Print or type name of person sign ig above Title
Please return this completed rescission request form to: 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: 91 M07-63001 FAX [phone]
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