NCG080425_Rescission Request_20200826

FOR AGENCY U$E ONLY
Division of Energy,Mineral & Land Resources i Date Received
Land QualitySection/Stormwater Permitting Program I Year Month ;i Day
LAN
National Pollutant Discharge Elimination System
Environmental RECEIVED
Quality RESCISSION REQUEST FORM
A1In 2 6 2020
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
DENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATEP PERMITTING
Individual Permit (or) Certificate of Coverage
N C S •
N C G b B o L LL_5
2) Owner/Facility Information: *Final correspondence will be mailed to thg address noted below
Owner/Facility Name �'y?/ ,5,5 T uc/
Facility Contact s /1jLeu
Street Address �'j 'oop ,sLdt.,-� b
City Lr°( r9�� - State 13C_ ZIP Code s-15
County e.j( E-mail Address /. f ldJtc i /tes5t !
Telephone No. q/D 3"2/ - (p?/ 5' Fax: .1/6:i 3 7/
3) Reason for rescission request(This is required information. Attach separate sheet if necessary:
n Facility closed or is closing on . All industrial activities have ceased such that no discl'arges of
stormwater are contaminated by exposure to industrial activities or materials.
n Facility sold to on . If the facility will continue operations unde-the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
C! Other: wE /-tqc,ENo X70,o.0 bie.41A>3 o4 l. ..35 ,) •K-r I
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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 inform ion is true, co and accurate.
Signatur Date
it, I Latact_ 1 Q 4t& AcL ,tt ' ACc
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 2018]an10