NCG200441_Rescission Request_20200611

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
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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 I C 1 S N I C I G 2 0 10 4 4 1
2) Owner/Facility Information: r Final correspondence will be mailed to the address noted below
Owne r/Fa cl llty Name OmuSource, LLC-NAliongton
Facility Contact donna wren.,
Street Address 2233 Wal-Pat Rd
City Smimriem State he ZIP Code 27377
County donnaton E-mail Address lamas.wmagar®ommaoum...
Telephone No. 919 9e9-310z Fax: - -
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 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 ire, complete and accurate.
Signature
Please return
Revised 20183an10
Z— ;
of person signing above
rescission request form to:
Date 06l10l20
Environmental Manager
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612