NCG080653_Rescission Request_20210602

RECEIVED
FOR AGENCY USE ONLY
NCGO6 O S JUN 02 2021
Assigned to: M- Web .- DENR-LAND QUALITY
ARO FRO MRO WARO WIRO SRO STORMWATER PERMITTING
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 recission of your NPDES stormwater permit.Prior to the recission of your NPDES stormwater permit,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:
USF Holland Inc. Jeffrey H. Coltnn
Street address: City: State and zip code:
10990 Roe Ave., MS-A650 Overland Park KS 66211
Telephone number: Email address:
[phone] [e-mail]
2. industrial Facility(facility requesting rescission):
Facility name:
USF Hollandrinc.-Greensboro
Street address:
201 Stage.Coach.Trig!
'
City: State: Zip Code: County:
Greensboro NC 27409 Guilford
Permit Number to which this request applies:
NCG080653
3. Reason for rescission Request
This is required information.Attach separate sheets if necessary.
®Facility is dosed 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: 10/25/2019
©Facility sold.
Sold to:
On date:
©Other(please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.6E(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).I hereby request exclusion from NPDES stormwater permitting.
Under penalty of law,I certify that:
O 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: Jeffrey H. Coltrin
Title:Vice President, Finance and Properties
al•-'"
41
(Sign ure of Appl cant) (Date Signe )ne
Mail the entire package to: DEMLR-Stormwater Program
Department of Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 2 of 2

ENVIRONMENTAL
May 25, 2021
Via: USPS Priority Mail Tracking No:9405 5036 9930 0397 0008 04
DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center r RECEIVED Raleigh, NC 27669-1612
RE: Rescission Request Form JUN 02 2021
USF Holland,Greensboro DENR-LAND QUALITY
201 Stage Coach Trail STORMWATER PERMITTING
Greensboro, NC 27409
Certificate of Coverage No. NCG080777
Dear Sir/Madame:
Enclosed please find a Rescission Request Form for the referenced facility. USF Holland ceased
operations at this facility on October 25,2019.
If there are any questions concerning this submittal, please contact me at [phone] or at
[e-mail].
Sincerely,
GEOS En ' .nmental, Inc.
—fri
r
ma .
Sr. olect Manager
Enclosures
Cc. Ruben Byerley,Yellow Corporation, PDF via email
C:\Users\YRC Stormwater Files\UHL\North Carolina\Greensboro\2021 NOT\NOT Transmittal Letter 05-25-21.docx
GEOS Environmental,Inc.
13014 N. Dale Mabry Hwy,No. 117
Tampa,FL 33618
www.geosenvironmental.com