NCG170358_Rescission Request_20240408

FOR AGENCY USE ONLY
Assigned to: S . C O V` A ��Fi�Fa
ARO FRO MRO RRO WARD WIRO WSRO
oe1k
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 NPDFS 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 ttem(4)below:
Coats HP, Inc Don Hager
Street address: City: State and zip code:
PO Box 1847 Kings Mountain 28086
Telephone number: Email address:
850-545-8142 [e-mail]
2. Industrial Facility(facility requesting rescission):
Facility name:
Coats HP, Inc
Street address:
300 Dickson Road
City: State: Zip Code: County:
Lowell NC 28098 Gaston
Permit Number to which this request applies:
NCG170000/COC NCG170358
3. Reason for rescission Request
This is required information.Attach separate sheets if necessary.
El 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: 1 January 2024
❑Facility sold.
Sold to:
On date:
❑Other(please explain):

4. Applicant Certification:
North Carolina-General Statute.1437215.6B.(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).I hereby request exclusion from NPDES stormwater.permitting.
Under penalty of law,I certify that:
El I,as an authorized representative,hereby request recission of coverage under the NPDES stonnwater 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: Todd J.Wegenast
Title: Environmental Compliance Manager
�BG a (�W4 44� 1 April 2024
(Signature of plicant) (Date Signed)
Mail the entire package to: DEMUR—Stormwater Program
Departrnent of Environmenta(Ctuality 4
1612�11Aa�I Se�v ce Center k
Raleigh,NC-27699-1612 ff
Page 2 of 2