NCG170037_Rescission_20210318

FOR AGENCY USE ONLY
Date Received:
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
Rescission Request Form
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program,1612 Mail Service Center, Raleigh, NC 27699-1612. The submission of this form does not
guarantee exclusion from NPDES stormwater permitting. Prior to exclusion from NPDES stormwater permitting a
site inspection will be conducted.
1. Owner/Operator (to whom all Dermit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed` in Item (4) below:
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Street address.
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City:
State and zip code:
Telephone number:
Email address: 9
2. Industrial Facilitv (facility reauestine rescission):
Facility name:
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Street address:
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City:
State:
Zip Code:
County:
Permit Number tothis request applies:
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3. Reason for rescission Request
I his is required intormation. Attach separate sheets it necessary.
Q Facility is closed or closing. All industrial activities have ceased such that no discharges of stormwater are contaminated
by exposure to industrial activities or materials.
Date closed/closing: `2-a
Facility sold.
Sold to: a. !'rl i ltS LIJ o-� L,c�S�z
On date: Z .
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4. Applicant Certification:
North Carolina General Statute 143-215.66 (i) provides that: Any person who knowingly makes any false statement,
representation, or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, 1 certify that:
" I, as an authorized representative, hereby request recission 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.
Printed Name of Person Signing:
Title:
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(Signature of Applicant) (Date Signed)
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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