NCG020652_COMPLETE FILE - HISTORICAL_20151210

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- STORMWATER-0IVISION CODING -SHEET
RESCISSIONS.
PERMIT NO.
DOC TYPE
I/COMPLETE.FILE -HISTORICAL
DATE OF
RESCISSION
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WYYMMDD

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Division of E;nergy..N ineral .Y Land Resources
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Land QualitYSection/Storniwaterl'cranittinl Program
National l'Otlam Dlsclre"Elimination 5V51emNeDE��
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RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Yeai
Monl'l Da
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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: 'C 5' N C G O p L4 Is,
2) Owner/Facility Information: ' Final correspondence will be�mailed to the address noted'below
Owner/Facility Name^ 1��'_S ��s r C
Facility Contact `� �� v"
treet Address
KI 0 y
-�
<ity
ounty
Telephone No.
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State
E-mail Address
Fax: 1-<'-
ZIP Code
•JA�
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3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
acility close r is closing on ,' . ' All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
Lo----
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❑ Facility cold to �` ��.: ' � on �xxL. 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 informatitrue,_.complet:e and accurate.
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Signature
Print or type name of person signing above
Date A2 1 J t
0G' -,
Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
RECEIVED1612 Mail Service Center
Raleigh, North Carolina 27699-1612
oCC 10 2015
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D NRL LAND QUALITY Pmtrie: 91 g-8i +-63001 FA,,, g 19-$07.6A92
STONAWAI'ER EMI >;tMITTIN4
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