NCG170125_Rescission Request_20210920

FOR AGENCY USE ONLY
Assigned to:
ARO FRO MRO RRO
WARO WIRO WSRO
RECEIVED
REP 2 0 2021
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 ftn whom ;all normit rnrr—.,.,...J,..... ..,:11
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
Carolina Mills Inc.
Michele Long
Street address:
City:
State and zip code:
618 N Carolina Ave
Maiden
NC 28650
Telephone number:
Email address:
[phone]
[e-mail]
2. Industrial Facilitv (farility rPrmortina rocri—innl.
Facility name:
Carolina Mills Incorporated - Plant 8
Street address:
618 N Carolina Ave
City:
Maiden
State:
NC
Zip Code:
Count y'
28650
Catawba
Permit Number to which this request applies:
NCG170125
I Reason for rescission Request
-uo a IaLlwiCU imurrnation. Hiiacn separate sheets if necessary.
El Facility is closed or closing. All industrial activities have ceased such that no discharges of stormwater are contaminated
rbyexposure to industrial activities or materials.
Date closed/cloing: 01/01/2017
Facility sold.
Sold to:
On date:
r7l 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:
17 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: Michele S Long
Title: CIO
(Signatur of Applicant)
Mail the'entire package to: DEMLR— Stormwater Program
09/20/2021
(Date Signed)
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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