NCS000348_Rescission Request_20221205

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DEC a 5 2022
FOR AGENCY USE ONLY V
Assigned to: (O
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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 NPDE.S 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 Ito whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
CPI USA North Carolina 1-LC-Southport Plant
Charles R Musselwhite
Street address:
City:
State and zip code:
1281 Powerhouse Drive
Southport
NC 28461
Telephone number:
Email address:
910-477-7090
[e-mail]
2. Industrial Facility (facility requesting rescission):
Facility name:
CPI USA North Carolina LLC-Southport Plant
Street address:
1281 Powerhouse Drive
City:
State:
I
Zip Code:
County:
Southport
NC
24861
Brunswick
Permit Number to which this request applies:
NCS000348
3. Reason for rescission Request

4. Applicant Certification:
North Carolina General Statute 143-215.613 (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:
0 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: Charles R Musselwhite
Title: Advisor, Environment, Health & Safety - Capital Power
11/22/2022
(Signature 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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