NCG030637_Rescission Request_20201230

Division of Energy,Mineral& Land Resources Date Received
IC
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System FOR AGENCY USE ONLY
Environmental
Quality RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. RECFIVF n
1) Enter the permit number to which this request applies: DEC3 0 2�
Individual Permit (or) Certificate of Coverage (_�
N C S N C G 0 3 0 6 .3 7LAND QUALITY
S(OKI .i ER PERMIT1 INC=
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name ABB Motors and Mechanical Inc
Facility Contact David W.Moore
Street Address 4401 East Dixon Blvd
City Shelby State NC ZIP Code 28150
County Cleveland E-mail Address [e-mail]
Telephone No. 704 476-3286 Fax:
3) Reason for rescission request(This is required information. Attach separate sheet if necessary):
0 Facility closed or is closing on 9/30/20 . 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 infor . . true, complete and accurate.
Signature Date t Z 7rr 7Zv
David W.Moore Plant Engineer
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