NCG020890_Rescission Request_20201006

Division of Energy, Mineral & Land Resources
Z Land Quality Section/Stormwater Permitting Program
� — National Pollutant Discharge Elimination System
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Chu" bey RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Dale Received
Year
I Month
Day
Please fill out and return this form if you no longer need to maintain your NPDES Stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or)
N C I S
Certificate
of
Coverage
2) Owner/Facility Information: 'Final cairespondence will be mafl d to the address I
Owner/Facility Names 1 1, i'1aL11C 1
Facility Contact Co (� r r
Street Address A I „, LL _
City (jU I I .per ln� _ State kx- ZIP
County 10 jZX MLp,t _ E-mail Address �1
Telephone No. G4 t,� _ Inl 7�1� Fax:
below
3)\,R�eason for rescission request (This is required information. Attach separate sheet if necessary):
�i 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 V Date (d �� �� �Q(r)
s 101 _Wli�Inna, �w
Print or pe name of person signing above Title
Please return this completed rescission request form to:
Revised 2018)an10
DEMLR -Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612