NCG170301_Rescission Request_20210713

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FOR AGENCY USE ONLY JUL 4 6 2021
N CG
~ DENR-LAND �JALITY
Assigned to: ARO FRO MRO WARO WIRO WSRp STORMtiIJATER 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:
Auria Troy, LLC
Todd Brandon
Street address:
City:
State and zip code:
163 Glen Rd
Troy
NC, 27371
Telephone number:
Email address:
910-572-3721
[e-mail]
2. Industrial Facilitv (facility reouestine rescission):
Facility name:
Auria Troy, LLC
Street address:
163 Glen Rd
City:
state:
Zip Code:
County:
Troy
NC
27371
Montgomery
Permit Number to which this request applies:
NCG170301
3. Reason for rescission Request
I III] 1.., IC[.iuI1CU III II itl L I UI I. MUc][.11 ]CpclI qiC )I ICCI-1 11 Y.
El 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: 7/3V21
0 Facility sold.
Sold to:
On date:
other (please explain):
TARGET CLOSURE DATE IS 7131121. NEW COMPANY WILL BE MOVING INTO BUILDING EXPECTED 811i21.

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
underthis 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 forth
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:'- z2—
Title: S� C iO/Z ev C—IP4- S
(Signature ofApplica (Date Sign d)
Mail the entire package to: DEMI.R —Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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