NCG210205_Rescission Request_20221216

FOR AGENCY USE ONLY
Assigned to: $• Ccro+\
ARO FRO MRO RRO WARO WIRO SRO
RECEIVED
DEC 16 2022
DEMLR-Stormwater Pr,,gram
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 storm water 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
gLiarantee recission of your NPDES stormwater permit. Prior to the recission of your NPDES stormwater permit, a
site inspection will be conducted.
1. Owner/Onerator (to whom all hermit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in item (4) below:
F'UGHES FURNITURE INDUSTRIES INC
A STEPHEN HUNSUCKER
St;' -et address:
City:
State and zip code:
PO BOX 486
RANDLEMAN
NC 27317
Telephone number..
336-302-6601
Email address:
[e-mail]
2. Industrial Facilitv (facility reauestiniz rescission):
Facility name:
HUGHES FURNITURE INDUSTRIES INC
Street address:
6676 HIGH PINE CHURCH ROAD
City:
State:
Zip Code:
County:
ASHEBORO
NC
27205
�RANDOLPH
Permit Number to which this request applies:
NCG210205
3. Reason for rescission Request

FOR AGENCY USE ONLY
Assigned to: $- Ctrv+h
ARO FRO MRO RRO WARO WIRO �SRO
RECEiV
DEC 16 2022
I)ENI-R-Stormwater rn:� r
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 storm water 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
tLiarantee recission of your NPDES stormwater permit. Prior to the recission of your NPDES stormwater permit, a
site inspection will be conducted.
1. Owner/onerator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in item (4) below:
KUGHES FURNITURE INDUSTRIES INC
A STEPHEN HUNSUCKER
Sti-et address:
City:
State and zip code:
PO BOX 486
RANDLEMAN
NC 27317
Telephone number..
Email address:
336-302-6601
[e-mail]
2. Industrial Facilitv (facility reauestine rescission):
Facility name:
HUGHES FURNITURE INDUSTRIES INC
Street address:
6676 HIGH PINE CHURCH ROAD
City:
State:
Zip Code:
County:
ASHEBORO
NC
27205
�RANDOLPH
Permit Number to which this request applies:
NCG210205
1
3. Reason for rescission Request
This is required information. Attach separate sheets if necessary.
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: 12/31/2020
0 Facility sold.
Sold to:
On date:
ll Other (please explain):
a

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 ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
0 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: A STEPHEN HUNSUCKER
Title: VICE PRESIDENT
(Signs re of A plicant) (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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