NCG080289_Rescission Request_20210824

FOR AGENCY USE ONLY
Assigned to:
ARO FRO MRO RRO WARO WIRO WSRO
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 storm water 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 nermit rorresnnndenrP will ha mailarll-
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
CRTS, Inc.
Barry B. Dale
Street address:
City:
State and zip code:
3301 Integrity Drive
Garner
NC 27529
Telephone number:
Email address:
919-773-4000
[e-mail]
2. Industrial Facilitv (facility reauestine resrissionl-
Facility name:
CRTS, Inc.
Street address:
3116 Capital Blvd
City:
State:
Zip Code:
County:
Raleigh
NC
27604
Wake
Permit Number to which this request applies:
NCG080289
3. Reason for rescission Request
i ins is ic4uneu nnviniauvn. Nllacn Sepdfdle SneeLs II 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:
❑ Facility sold.
Sold to:
On date:
I] Other (please explain):
Former operations at Capital Blvd. ceased in May 2001. Integrity Dr. location began in May 2001.

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:
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: Barry B. Dale
Title: Vice President
— /""' a '�- - At49IL ao2
(Sign ture 4 Applicant) (Date Signed)
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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