NCG050372_Rescission Request_20230823

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ARO FRO MRO RRO WARD WIRO SRO AN 3 2021 DEMLR-swowaw 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 of legal organizational entity: Legally responsible person as signed in Item(4)below:
Unilin Flooring Jennifer Teague
Street address: City: State and zip code:
550 Cloniger Dr Thomasville NC 27360
Telephone number: Email address:
336-313-4231 x54231 [e-mail]
2. Industrial Facility(facility requesting rescission):
Facility name:
Unilin Flooring-Denton Road
Street address:
3286 Denton Rd
City: State: Zip Code: County:
Thomasville NC 27360 Davidson
Permit Number to which this request applies:
NCG050372
3. Reason for rescission Request
This is required information.Attach separate sheets if necessary.
Fonis dosE
ng.All industrial activities have ceased such that no discharges of stormwater are contaminated
re to ictivities or materials.
ate clg:
sold.
old toderson GNA Holdings LLC dat2
(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.
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: Jennifer Teague
Title: EHS Manager
4 �� �o a3
( i ature of pplicant) (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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