NCG200446_Rescission Request_20210618 (2)

FOR AGENCY USE ONLY
NCG_ _ _
Assigned to:
ARO FRO
MRO WARO WIRO WSRO
REOFI1 ED
JUN 15 2021
DENR-LAND QUALITY
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 NPDE'S 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:
Renew Recycling LLC
Jody Standley
Street address:
City:
State and zip code:
440 13outh Tech Park Lane
Clayton
NC, 27520
Telephone number: ...... ......
'E,mail..ad.dress:..,.
919-550-8008
[e-mail]
2. Industrial Facility (facility reauestinR rescission):
Facility name:
Wise Recyclinq 'f LLC
Street address:
550 Wise",Rd
City:
State:
Zip Code:
County:
[Johnson
Clayton
NC ,,.
27526:,,
Permit Number to which this request applies:
NCG200446
3. Reason for rescission Request
irlls IS ItgUHeU IFiIUrrrid LlUn. /AUdCn separ-ate sneets a necessary.
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: June 18, 2012
El Facility sold.
Sold to:
On date:
® other (please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.613 (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 stormwater permitting.
Under penalty of law, I certify that:
0 1, 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:
!loo/
(Signature of Applicant) (Date Si ned)
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