NCG130051_Rescission Request_20230206

RECEMED
FOR AGENCY USE ONLY
Assigned to: • C&V FEB 07 2023
ARO FRO MRO FRO WARO WIRO SRO
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: NCDEMLF
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):
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
Waste Industries, LLC
Benjamin Habets
Street address:
City:
State and zip code:
3301 Benson Drive, Suite 601
Raleigh
NC, 27609
Telephone number:
Email address:
919-201-3033
[e-mail]
2. Industrial Facility (facility requesting rescission):
Facility name:
Waste Industries LLC
Street address:
3909 Riverdale Road
City:
State:
Zip Code:
County:
Greensboro
NC
Gilford
Permit Number to which this request applies:
NCG130051
3. Reason for rescission Request
wua
E3 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: Harper Riverdale
Other (please explain):

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:
❑ 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: Benjamin Habets
Title: Area Vice President
Waste Industries, LLC by:
(Signatu of Applicant)
Mail the entire package to: DEMLR—Stormwater
1 /2f7/2023
(Date Signed)
/ice Center
699-1612
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