NCS000023_Rescission Request_20200623

FOR AGENCY USE ONLY
• Division of Energy,Mineral&Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month I Day
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
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 c s 0 0 0 0 2 3 N C G.
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name Good Earth Horticulture Inc.
Facility Contact Guenter M.Burkhardt
Street Address 5950 Broadway
City Lancaster State NY ZIP Code 14086
County Erie E-mail Address [e-mail]
Telephone No. 716 684-8111 Fax: 716 684-3722
3) Reason for rescission request(This is required information. Attach separate sheet if necessary):
✓❑ Facility closed or is closing on 12/2019. 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: The facility located at 694 Griffin Farm Road,Star NC 27356,has not been in operation since July 2009.
The facility has been cleaned and items of concern by the NCDEQ have been removed and photos of this have been forwarded to
the DELI in December of 2019.
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.
i3 jpap
Signature 601 Date June 23,2020
Guenter M. Burkhardt VP
Print or type 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 20183an10