NCG060249_Rescission Request_20200611

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
'duality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
I
RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.y ail
DENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N I C I s I I I I I I I IN I 0 I 0 10 16 10 T2 4 9
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Wayne Farms LLC Elkin Poultry Feed Mill 2
Facility Contact
Street Address
City
County
Telephone No.
Jeremy Bowlin
PO Box 383
Dobson
Surry
336-386-5867
State NC
E-mail Address
Fax:
ZIP Code 27017
jeremy. bowlin@v✓aynefarms.com
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: Facility never built, and we have no intentions of building it.
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 tr e, complete a d accurate.
Signature Date 0 d Za2.0
Cory Early Complex Manger
Print or type name of person signing above
Please return this completed rescission request form to
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 20183an10