NCG180104_Rescission Request_20220825

FOR AGENCY USE ONLY RECEIVED
Assigned to: q .t
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OCPJR-LAND QUALITY
STORE""NA'TER PERMITTING
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):
2. li
Name of legal organizational entity:
Legally responsible person assigned in Item (4) below:
Vaughan -Bassett Furniture
Cory Jackson
Street address:
City:
State and zip code:
300 East Grayson Street
Galax
VA, 24333
Telephone number:
Email address:
2762366161
[e-mail]
ioustrlal Fac
Facility name:
Furniture- Elkin
Street address:
501 East Main Street
City: State: Zip Code: County:
Elkin I NC 28621 Surry
Permit Number to which this request applies
NCG180104
3. Reason for rescission Request
i nis is regwreu unorrnduun. ALLdcn bepa[dLU bnecu a ne�ebbary.
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: Sycamore Construction Group - Jon Dillon
on date: 09/09/2021
DOther (please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.6E (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 ($50,000). 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: Cory Jackson
Title: Vice -President of Engineering and Industrial Efficiency
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(Signs of 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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