NCG030494_Rescission Request_20230303

FOR AGENCY USE ONLY
Assigned. B- COOK
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E101 (' Division of Energy, Mineral, and Land Resources Land Quality Section
43A13032j 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
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):
2. 1
NZ of legal organizational entity:
Legally espon1sible pers
signed in Item (4) below:
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Street address:
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co State n zi de:
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Tel hone number-
Email address: ^_
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ndustrial Facility (facility requesting rescission)
F cili namQ:,
Street address:
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Permit Number to which this request applies: LC
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3. Reason for rescission Request
i ms i quirea inrormation. vttacn separate sneets it 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.
y sold.
Soldto:,-:r",-,d
Other (please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.6E (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.
Und enalty 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:
a / 2 c [7-3--
(Signature of Applicant) (Dat4 Si ned)
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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