NCG050006_Rescission Request_20210505

FOR AGENCY USE ONLY
Date Received: �� 0a
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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 permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in item (4) below:
3A Composites
John Sutton
Street address:
City:
State and zip code:
Two Harbour Place 721 Jetton Street suite 325
Davidson
NC 28036
Telephone number:
Email address:
704-838-7057
[e-mail]
2. Industrial Facility (facility requesting rescission):
Facility name:
3A Front Street
Street address:
2020 West Front Street
City:
State:
ING
Zip Code:
County:
Statesville
28677
Iredell
Permit Number to which this request applies:
NCGO50006
3. Reason for rescission Request
This is required information. 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:
Facility sold.
Sold to:
On date:
Other (please explain):

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, I certify that:
Ell, 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: John C. Sutton
Title: CFO
V/2ah)
(Sig re of Applicant) (Date Signed) _
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quallty
� - 4.\
1612 Mail Service Center "''
Raleigh, NC 27699-1612
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