NCG210171_Rescission Request Form_20200526

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
K National Pollutant Discharge Elimination System
En r r'metttat
Quatity RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Fmonth
Day
RECEIVED
MAY %6 : 1
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
DENR•LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTP
Individual Permit (or) Certificate of Coverage
N'I c I S N C I G 1 2 1 0 1 7 1 1
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/ Facility Name Cook nrothers I_uml,erCon:_,wiy
Facility Contact
Street Address
City
County
Telephone No.
Leonard Cook
85 Peaceful Cove Road
Franklin State NC
Macon E-mail Address
[phone] Fax:
ZIP Code 28734
[e-mail]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑r Facility closed or is closing on 1/1/20 . 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 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 Date— 4:.nnl "-_�
Leonard Cook
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 20183an10
President and Owner
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612