NCG020756_Rescission Request_20200826

It'11Z.— Division of Energy,Mineral&Land Resources Date Received
Land Quality Section/Stormwater Permitting Program FOR AGENCY USE ONLY
Year I Month I Day
National Pollutant Discharge Elimination System J
Environmental
Quality RESCISSION REQUEST FORM RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. b 2))7n
DENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTINC-
Individual Permit (or) Certificate of Coverage
INICISI III I I I INICIGIOI2Io i-1ls1G !
2) Owner/Facility Information: �4_*"Final correspondence will be mailed to the address noted below
Owner/Facility Name fir;cA I 4 Sne CoNs ucis;Dn l'Tnc.
Facility Contact Fr ate L wt,fn e
Street Address b. 4i g3$
City 0-nia- t State IUC ZIP C de chi S(13
County CaLutm6tks E-mail Address he-P-0
Telephone No. 6110 Colt 3 - h$03 Fax: 9i0 tote;- 1 i qer
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
Er 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 is true, complete and accurate.
Signature t -4f 1120 lac.
Date
Eats- k 6l►e P(es` cle,- '
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