NCG030251_Rescission Request_20211130

FOR AGENCY USE ONLY,q ^ /
Assigned to: 4 • cARsy/ V
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Division of Energy, Mineral, and Land Resources Land Quality Secti& `d � 0 2021
National Pollutant Discharge Elimination System DEWAND QUALI rY
Rescission Request Form STORMWATER PERM11TING
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:
Watts Regulator
Brad Bowen
Street address:
City:
State and zip code:
100 Watts Road
Spindale
NC 28160
Telephone number:
Email address:
828-980-6050
[e-mail]
2. Industrial Facilitv (facility requesting rescission):
Facility name:
Watts Regulator
Street address:
100 Watts Road
City:
State:
Zip Code:
County:
Spindale
NC
28160
Rutherford
Permit Number to which this request applies:
NCG030251
3. Reason for rescission Request
rs regmrea rmormduon. AtLdar Wpdrdie mracu u
0 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:
0 Facility sold.
Sold to:
On date:
[3Other (please explain):
Facility operations no longer covered under NCG03 - Metal Fabrication; facility requesting coverage under NCGO6 - Warehousing

4. Applicant Certification:
North Carolina General Statute 143-215.6B (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, 1 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: Brad Bowen
Title: Operations Manager
7
(Signature of Applicant) (Date igned)
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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