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FOR AGENCY USE ONLY APR
Date Received: / 1 DENR L
Division of Energy, Mineral, and Land Resources L� fibn
National Pollutant Discharge Elimination System R'Mf1771V
Rescission Request Form
Please fill out and return dais form if you no longer need to maintain your NPDES storm water permit.
Directions: Print or type all entries on this application form. Send the original, signed application to: NC7El)
Stormwater Program, 1612 Mail Service Center, Raleigh, NC 27699-1612. The submission of this form does r
guarantee exclusion from NPDES Stormwater permitting. Prior to exclusion from NPDES stormwater permittin
site inspection will be conducted.
1. Owner/Operator (to whom all permit correspondence will be mailed):
Narne of legal organizational entity: 1 Legally responsible person as signed in !tern (4) below:
i
Street address: City: State and zip code:
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Telephone number: 1 Email address:
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2. Industrial Facility (facility requesting rescission):
(_Facility name:
Street address:
City: State: Zip Code: County:
Permit Number to which this request applies:
3. Reason for rescission Request
'This is required information. Attach separate sheets if necessary.
4 Facility is closed or closing. All industrial activities have ceased such that no discharges of stormwater are contamina
by exposure to industrial activities or materials.
Date closed/closing: aP 2 i L- --7 , i `l
0 Facility sold.
Sold to:
On date:
Other- (please explain):
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NC - MEBANE --/-/B080 I Sale Date: Wed. Mar 03, 2021 - 10:00 AM EST
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4^ Applicant Certification:
North Carolina General Statute 143215.68 (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 rnaintai
underthisArtideora/u|eimp|ementingthisAndde...yhaUbegui|tyofaOassZmisdemeanorvvhichmayindudeafinE
to exceed ten thousand dollars ($10,000). 1 hereby reqUest exclusion from NPDES stormwater permitting.
Under penalty cflaw, | certify that:
91 1, as an authorized representative, hereby reqLjest recission of coverage Linder the NPDES stormwater Permit for tile
subi . ect facillty� I am familiar with the information contained in this request and to the best of my knowledge and bf
such information is true, complete, and accurate.
Printed Name of Person Sighing:
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(Dnte@gned
Mail the entire package to: DEMLR—BormwaterPnogram
Department ofEnvironmental Quality ^"
1612Mail Service Center
Raleigh, NC27699'l612
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