NCG070190_Rescission Request_20210302

N. Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
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 I C I 5
2) Owner/Facility Information:
Owner/Facility Name
Facility Contact
Street Address
City
County
Telephone No.
* Final correspondence will
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Certificate of Coverage
N C G Q 0 / (�
to the address noted below
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State (f— ZIP Code r1�
E-mail Address ct n cc//-e W S
Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
Facility closed or is closing on pJ0
If . 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 appropriatetorequest an ownership change to reissue to permit to the new owner.
Other: e_L5 e c Sd /oQ ] a7-4 " D/ 77}ry
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4) Certification:
I, as an authorized representative, hereby request rescission of coveraye under the NPDES StormwaLer vermit 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 , co plete and accur
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Signature V Date 2
tr' o - 0 o i7 eof-
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
/� /� ll Raleigh, North Carolina 27699-1612
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