NCG080939_Rescission Request_20220928

RECEIVED
FOR AGENCY USE ONLY
As sj'E n e d to: $- W
RO FRO MRO RRO WARO WIRO WSRO
OEMLP-Storrnwater Program
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 Mall Service Center, Raleigh, INC 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:
CSX Transportation, Inc.
Samuel Ross
Street address:
City:
State and zip code:
500 Water Street, J275
Jacksonville
Florida 32202
Telephone number:
Email address:
904-359-3691
samuel [e-mail]
2. Industrial Facility (facility requesting rescission):
Facility name:
Bostic Rail Yard
Street address:
279 Bostic Yard Road
City:
State:
Zip Code:
County:
Bostic
I North Carolina
27502
Rutherford
Permit Number to which this request applies:
NCGO80939
3. Reason for rescission Request
ms is requrreu mrormauon. Attdcn separate sneea n necessary.
❑ 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:
❑ Facility sold.
Sold to:
On date:
El Other (please explain):
Industrial activities at this facility, which included direct -to -locomotive fueling, no longer occur on -site.

4. Applicant Certification:
North Carolina General Statute 143-215.66 (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). I hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
O 1, 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: Samuel Ross
Title: Director Environmental Field Services
'Z nq • 4,
(Signature of Applicant)
9/26/2022
(Date Signed)
Mail the entire package to: DEMUR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 2 of 2

Samuel Ross 600 Water Street, J275
Director Environmental Field Jacksonville, FL 32202
Services 904-359-3691
Fax [phone]
[e-mail]
September 26, 2022
NCDEMLR Stormwater Program
1612 Mail Service Center
Raleigh, NC 27699-1612
Re: Rescission Request Form
CSX Transportation, Inc. Bostic Yard
Permit No. NCGO80939
Dear Sir or Madam,
Attached is a copy of the completed request form for this facility.
If you have any questions or comments, please do not hesitate to contact me at 904-359-3691.
Sincerely,
'- 3SIintTBi Ros
Attachment
RECEIVED
DEMLR-Stormwater Program