NCG190102_Rescission Request_20200813

Division of Energy,Mineral& Land Resources Date Received
Year Month Day
:'''
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System FOR AGENCY USE ONLY
Environmental
Quality RESCISSION REQUEST FORM c C ` 'c
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.ECEI V GD
AUG 13 2020
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage DENR-LAND QUALITY
N C S' I CIO rI4r�DQ,li R PERMITTING
2) Owner/Facility I nfor tion: *Final correspondence will be mailed to the address noted
below
Owner/Facility Nam t'HQ1 !'(1Ct i ne 2P1v « te
'l S L LE
Facility Contact fide ki0ON- -
Street Address © " a
City State KC. IP Code )-
County _ E-mail Address Q
Telephone No. Fax: rY1��lr1
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 ownershi change to reissue t permit to the new owner.
Yj Other: E' 1 c 7 owr s.A I i ) n �# p • C
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.
IDSignature DateP r 3 1 I t 2G 2_0
t c�6 \ D L� ��' D . A 0Lunee
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 2018Jan10