NCG140207_COMPLETE FILE - HISTORICAL_20180620

STORMWATER DIVISION CODINGSHEET
RESCISSIONS .
PERMIT NO.
DOC TYPE
❑COMPLETE
FILE -HISTORICAL
DATE OF
RESCISSION
❑
� U
YYYYMMDD

RECEIVE)
JUN 2 0 2018
CENTRAL
�FILES
Division�iF'1?rle �;" innoeral & Land Resources
Land Quality Section/Stormwater Permitting Program
ANN
NCDENRNational Pollutant Discharge Elimination System
FOR AGENCY USE ONLY
Date Recaived
Year
I Month
Day
�rt.r C­ Dww __ a, f c
RESCISSION REQUEST FORM RF-CEtVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. MAR 15 201J
1) Enter the permit number to which this request applies:
Individual Permit (or)
N G .5
DENR-LAND QUALITY
Certificate of Coverage VORMWATER PERMITTING
•:N :C .G.
2) owner/Facility Information: • Final correspondence will be mailed to the address noted below
Owner/Facility�-
Facility Contact � 0i�1L'
Street Address �oQ m� t h . L
city E'c-C li r� �� State G ZIP Code aR (n4
County Lz_ ir\1 z>y-t E-mail Address C-A en) . Cc--rY- n k-5
Telephone No. 2 1 2) -a 1 n 2, Fax:
3) Reason for rescission request (This is reatilred information. Attach separate sheet if necessary):
Facifit closed r 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 -
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 infor ation is true, complete and accurate.
Co rr Q-(n'5
Print or type name of person signing above
Date a.{
Di rt--,
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 M07-6300 t FAX: [phone] f � ^ � 7) 2,
An Equal Opponunity j Affirmative Action Emplo es I k 0 c, ' Y v VV s