NCG210441_Rescission Request_20210225

Environmental
€Arty
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
RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
201
L _: r\-Lf N1_) CCU 11TY
1) Enter the permit number to which this request applies: J;!.1'�`u'A7ER PL_R �I`fTING
Individual Permit (or) Certificate of Coverage
N I c I S N C G 2 1 10 14 4 1
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Capital Materials & Recycling, LLC
Facility Contact
Street Address
City
County
Telephone No.
Tracy Green
8310 Bandford Way
Raleigh State NC
Wake E-mail Address
919 781-3744 Fax: 919
ZIP Code 27615
[e-mail]
845-3080
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ 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 WJD Holdings, LLC on Vo\ q . 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 is request and to the best of my knowledge and belief
such information is true, complete and a ra
Signature 2/17/21
9 e Date
J.('j" Loftin, Jr.
Print or type name of person signing above
Please return this completed rescission request form to
Manager
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10