NCG190060_Rescission Request_20220322

N66I 60
FOR AGENCY USE ONLY
Assigned to:
ARO FRO MRO RRO WAR WIRO WSRO
RECEIVED
MAR ? 2 2022
DENR•LAND QUALITY
STORMWATER PERMITTiN(3
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/Ooerator Ito whnm all nermit rnrrpcnnndpnrp will ha mailprll-
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
Anchor's Away Boatyard, Inc.
Paige Brown
Street address:
City:
State and zip code:
PO Box 279
Hampstead
NC 28443
Telephone number:
Email address:
(910 ) 338-8773
[e-mail]
2. Industrial Fac
Facility name:
Anchor's Aw tyard, Inc.
Street ad s:
585 Lew
City: state:
Permit Number to which this request applies:
190060
3. Reason for rescission Request
This is required information. Attach separate sheets if necessary.
County:
Pender
10 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:
C3 Facility sold.
Sold to:
On date:
El Other (please explain):
Company lost lease. Property is being leased to another company

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, 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: Paige Brown
Title: Office Manager
(Signature Applicant)
Mail the entire package to: DEMLR— Stormwater
March 10, 2022
(Date Signed)
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