NCG020417_COMPLETE FILE - HISTORICAL_20180214

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV C& ba (:)Y 1 -7
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ab)SJal'4
YYYYMMDD

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wa'A) - - LF
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biyision or Energy, Mineral & Land Resources
Land Quality SectionlStormtiyater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FORAGE YVSE 011Y FOR AGE Y USE ONLY
Date Received
Year
I Month
I Da
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 I C 1 5 1 J M I I N t G a l
2) owner/Facility Information: • Final correspondence will be maUed to the address noted below
Owner/Facility
Facility Contact
Street Address
City
County _
Telephone No.
3) Reason for rescission request (This is uFsu redl Information. Attach separate sheet if necessary):
Ml-a-cli;it—y closed or is closing on 91." . All industrial activities have ceased such that no discharges of
slormwater are contaminated by exposure to industrial activities or materials.
. C.D r'''%
❑ 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.
❑ 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 information is true, complete and accurate.
Signature C.61 (2��*Se—a Date TT !
le sa-e L.. ,%x Li l o.;.,ne.y-
Print or type name of person sigmt 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
P RECEIVED
Revised 20187anIO
FEB 13 2018
DENR-LAND QUALITY
STORMWATER PERMITTING

-I
Edgerton, Thom
From: Alexander, Laura
Sent: Thursday, September 13, 2018 9:47 AM
To: Edgerton, Thom
Subject: FW: NCG020417 Rescission Request
Attachments: Xerox Scan 02142018122231.PDF
Good Morning,
My last day with DEMLR is 9/21/18. Just following up on this request.
Please send any permit correspondence to Annette Lucas or Bethany Georgoulias in the future.
Stay safe.
Regards,
Laura Alexander
From: Alexander, Laura
Sent: Wednesday, February 14, 2018 12:25 PM
To: Edgerton, Thom <thom.edge [e-mail]>
Subject: NCG020417 Rescission Request
Thom,
See attached rescission request. BIMS states Hertford county but the owner says Pitt county.
Thanks,
Laura
i

FOR AGENCY USE ONLY
� 1 �
Division of Energy, Mineral & Lard Resources Data Received
t .1 land Quality Section/Stormwater Permitting Program Year I MmU I Da
'
National Pollutant Discharge Elimination Systcm
' RESCISSION REQUEST FORM
Please fill out and return, this form if you no longer need to maintain your NPDES stormwater permit.
11 Enter the permit number to which this request applies:
Individual Permit for) Certificate of Coverage
N I c I s N I c I G 10 1,:21014117
..2) Owner/Facility Information: • Final correspondence will
be nwlled to the address noTC_-
below
Owner/Facility Name. L),n 1,-)Vl S" Ln dt
rd (2:wa VC.� 1:he
FaciContact
t—e—
Street Address
`L I
City1
-
County
Telephone No.
p�
State Ar— ZIP Code
E-mail Address cG e
Fax:
�I . C.o r­
3) Reason for rescission request (This is requite Information. Attach separate sheet if necessary):
acuity closed or is closing on I . 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 fatality 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:
f, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
'subject fatality. 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.
'Signatures---- _ Date�3,
le s�-e L . '%
Print or type name of person sigrA 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
rRECEIVED
FEB 13 2016
Revised 20183an10 DENR-LAND QUALITY
STORMWATER PERMITTING