NCG180259_recission request_20230426

FOR AGENCY USE ONLY ECEIVED
Assigned to:
ARO FRO MRO RRO WARO WIRO WSRO APR 2 6 1023
;)EMLR.Starmwater Program
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: 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):
Name organi�za�tional a/ntity: J' Legally res onsible pers�oLn.�as signed in Item(4) below:
Street a�dereess: - City: St at and zip cocle.�
Telephone number: / Email address: !
2. Industrial Facility (facility requesting rescission):
Facility name.
Street address:
City: State: Zip Code: County:
Permit Number to which this request applies:
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:
acility sold. /
Sold to: C T-117 ✓Y-64 ., 44
On date: y /> ;;2-3
El Other(please explain):