NCG200461_Rescission Request_20210608

FOR AGENCY USE ONLY
NCG_2-a 0 4 6 I
Assigned to: t,k • M-el on
ARO FRO 4& WARO WIRO WSRO
Division of Energy, Mineral, and Land Resources Land Quaki�,9&-ED
National Pollutant Discharge Elimination System JUN ®g 2021
Rescission Request Form DENR-LAND QUALITY
STORMWATER PERMITTING
Please f// 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:
Elan Trading, Igg dDg 5guMM R= s
Elisa Waldman
Street address:
City:
State and zip code:
801 E Morehead Street Suite 105.1004
Charlotte
NC 28202
Telephone number:
..Email address:.-....
..
704-342-1696 _ �°
.,�� 2
'.ids,rfT'js'�+.'.#'aiiFF•'cX.'.Y,.cfA' ,•'.':?t RK,;4�.'.*,$tw.. '
Info` vii+� come oumewhome.coni
2. Industrial Facility (facijkAtesi
Facility name .
Southern R
Street adds::. KN'`'
3826 Ra tt�
City: State
Permit Number to which
t as"request app yes:
3. Reason for rescission Request
Apt -de:.
noon
i rns is requires mrormation. ALEacn separate sneers IT necessary.
�Cortltty' .
0 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: 3/2020
® Facility sold.
Sold to: 3826 Raleigh Street, Inc
On date: 2020
©Other (please explain):

4. Applicant Certification:
North Carolina General Statute 143-315.613 (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 stonnva¢erpenmittin8.
Under penalty oflaw, | certify that:
El 1,asenauthorized representative, hereby request reoisaionmfcoverage under the NPDES stonnxwete,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 istrue, complete, and accurate.
Printed Name mfPerson Signing: EgisaVVald00aO
5/2021
(Signature of Applicant) (Date Signed)
Mail the entire package to:
DEM
^