NCG020399_Rescission Request_20200826

Piz°2a.Selkaav L NCe nr.
994
FOR AGENCY USE ONLY
Division of Energy,Mineral& Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Monty, Day
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. AUG 2 6ro
DENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N C S N C G O 2. Q3 _l 9
2) Owner/Facility Information: *Final correspondence wwill be mailed to the address noted below
Owner/Facility Name Ciebz-ko �C1STC-1,1C_\Q(1 Comc&n`11 rcc.
Facility Contact
Street Address P Q aOX laQO
City 1A a V e✓ t OGEC State NC. ZIP Code 2_8532
County C—r&V e.0 E-mail Address /!,.1r3t-i @-C.3,e,Szko CorN*11.ACki0 4-CCIM
Telephone No. 2.5Z .-IL11• ZOgl° Fax: ZSZ A-14A1 Oto ca _
3) Reason for rescission request(This is required information. Attach separate sheet if necessary):
Facility closed or is closing on S iAll 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 contane. this request and to the best of my knowledge and belief
such information is true, co slete and accurate.
Signature Date Z o J ZOZO
C •
te?.s=, GL►a r' Mai')
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