NCG100228_Rescission_20200903

FOR AGENCY USE ONLY
Division of Energy,Mineral& Land Resources oats Because
Land Quality Section;Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System
Envtronntenral ''ECEIVED
Quality RESCISSION REQUEST FORM
SEP 0-3 2020
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
DENR-LAND QUALITY
TORMWATER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
l 1010228
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name LKQ Southeast Inc dibia LKQ Heavy Truck Chariotte
Facility Contact Brandon Walsh
Street Address 2030 Lucas La
City Nashville State TN ZIP Code 37207
County Davidson E-mail Address bswalsh(glkqcorp.corn
Telephone No. (615) 477-9833 Fax:
3) Reason for rescission request(This is required information. Attach separate sheet if necessary):
❑r Facility closed or is closing on 7/31/20 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 a ate.
n ...t
Signature `—" rA, Date
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 20183an10