NCG020629_Rescission Request_20200819

FOR AGENCY USE ONLY
Division of Energy,Mineral& Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System Environmental R E r�L.w F I`.!E D
Quality RESCISSION REQUEST FORM
AUG 19 2020
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permitljENR LAND QUALITY
STORMWATER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C S N C G o a 0 lQ p. g
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name St daft Tru cKi n9 inc .
Facility Contact M itCh St U G1 i r
Street Address ),O Sj e. Li th street _
City washinAton State ('4G ZIP Code algal _
County 6.[a(,(Arr E-mail Address St.CIO\rtYUct i Ahoo. corn
Telephone No. asa-qy(P- —1g5c1 Fax: asa-oviii- 5801
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: We V-iep- Policy in wise we needed it WVe have not
p up)r ped water Ln +e ears SD we no I onoer `need poi i ci3
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
mT Cic ,fpt.taizetoli-
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