NCG100169_Rescission_20211022

FOR AGENCY USE ONLY
Assigned to: S •
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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:
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Legally responsible person as signed in Item (4) below:
Street address:
Telephone number: _
City:
State and zip code:
Email address:
2. Industrial Facilitv (facility requesting rescission):
Facility name:
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Street address:
City:
State:
Zip Code:
County:
Permit Number to which this request applies:
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3. Reason for rescission Request
I nis is requirea information. Httacn separate sneers it necessary.
acility 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:
El Other (please explain):

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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:
❑ 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:
Title: N i &n e
(Signature of Ap ant) (Date Signed)
Mail the entire package to: DEMLR — Stormwater Program
Department of'En'ir`onmental'
(Return This Portion With Check)
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ANNUAL PERMIT INVOICE pen �u
Invoice Number: 2021 PR007174
Permit Number: NCG100169
Randolph County
Beck's Used Cars
Mitchell R. Beck
Mitchell R. Beck
3142 Beck Cntry Dr
Randleman, NC 27317
Annual Fee Period: 2021-09-01 to 2022-08-31
Invoice Date: 8/2/2021
Due Date: 9/1/2021
Annual Fee: $100.00
Check Number:
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