NCGNE0758_Rescission Request Form_20170613

1C
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
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 I Month
Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwate
1) Enter the permit number to which this request applies:`?
Individual Permit (or) Certificate of Coverage
IN I C IS I I I I IN I C I GIN I E 1 0 7F5T 8
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Axalta Coating Systems, U.S.A, LLC ["Axalta"]
Facility Contact
Street Address
City
County
Telephone No.
W Mark Schau
1647 Enalish Road
High Point State NC
Guilford E-mail Address
[phone] Fax:
ZIP Code 27262
mark.schaueaxaltacs.com
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on 11/3ni2oog All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
® Facility sold to Axalta on o6101/2o17 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 f rue, complete and accurate.
�lA ® . .
06/12/2017
Signature Date
Denise Trabbic-Pointer Global Environmental Competency Leader
Print or type name of person signing above Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer