NCG200356_Rescission Request_20191227

FOR AGENCY USE ONLY
Division of Energy,Mineral& Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System
Environmental P F(''.F 4\/F
Quality RESCISSION REQUEST FORM DEC 27
201
Please fill out and return this form if you no longer need to maintain your NPDES stormwater perrf*NR-LAND QUALITY
STORMWATER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C 5 N C G 2 0 0 3 5 6
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name Consolidated Pipe&Supply Company,Inc.(CPS)
Facility Contact Mr Steve Pagley
Street Address 1630 North Greene Street
City Greenville State NC ZIP Code 27834
County Pitt E-mail Address spagley@consolidatedpipe corn
Telephone No. 252 754-0700 Fax: 205 578-4828
3) Reason for rescission request (This is required 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 CPS 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: CPS will use the land as a distribution center for its pipe,valves and fittings business and maintain a rental shop for related equipment. No manufacturing or
demolition or recycling occurs at the facility any longer.
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.
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�Signature 4 � Date
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Print or ty�e 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