SW3190703_Permit Rescission Request Form_20211108

DEMLR USE ONLY
Date Received
BIMS Rescission Date
Permit Number
II Z0
I 2oif
S'w 3190-7
NC DEQ Division of Energy, Mineral and Land Resources RECEIVED
STATE STORMWATER:
PERMIT RESCISSION REQUEST FORM NOV 0 8 2021
ONLY for when the permittee of record wishes to rescind an existing State Stormwater Management J,&ALi T Y
one of the options below. The permittee must complete, sign and submit this original form to the approp P111iTING
DEMLR Regional Office, which can be determined by locating the project on the interactive online map at:
http://deg. nc. gov/contact/regional-offices.
1. State Stormwater Permit Number
2. Project name: V� Z y
a C_
3. )K I am the current permittee of the permit to be rescinded. (if you are not the current permittee, either the
current permittee must complete this form or you must apply to transfer the permit and receive
approval before you can apply to rescind the permit).
4. Rescission options (select only one response below)
❑ a. This project has been or will be replaced by a separate permit issued by the Division.
❑ If the new permit number has been assigned: SW
❑ If a new permit number has not been assigned, the proposed facility name:
b. This project has not been constructed and there are no future plans to do so under this approval. I
understand that any vested rights or prior authorizations are forfeited based on this request.
❑ c. This project has received approval from the City of Wilmington under their post -construction ordinance
which includes and covers both the previously approved construction under the State permit, and all
subsequent new construction. A copy of the new permit issued by the City of Wilmington must be
submitted along with this form.
❑ The permit / approval number issued by the City of Wilmington:
❑ I acknowledge and understand that this delegated local government may impose stricter design
requirements for the existing part of the project.
❑ I acknowledge that this delegated local government may assess annual fees for its stormwater
permits. For comparison, the State charges $505.00 to transfer a permit or to modify a permit, and
$505.00 every 8 years to renew a high -density permit.
Signature requirements for the named signing official representing the current permit holder must meet the
requirements listed in NCAC 02H.1040(1).
I, b "'A �0.�+� � the current permittee, am submitting this request to
rescind the above -listed stormwater permit. I attest that this request for a permit rescission is made with the full
knowledge and understanding of the above -listed facts. I understand that the subject state stormwater permit will not
be rescinded until a copy of the permit issued by the delegated local government is submitted to DEMLR, or the
replacement permit is issued,,pr it ip p6nfirmed that the project has not been constructed.
Signature:
Date: 16 / 2 b /2 1
I, 0-0"Y ok. V1 i ViA i xtDYl , a Notary Public for the State of
NQX-Nm C yL)b lid County of \ _Y F l I , do hereby certify that
wk�\1Cl m personally appeared before me this the
day of Y_ 20 2 and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal, (Notary Seal)
Q 0 i
Notary Signature: = v Notary Publicuwi
Z
fired ll
My commission expires County
Stormwater Permit Rescissinn RenuPst Fnrm Page 1 of 1 //O 'Li,�TN March 14, 2019
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