NCG200442_Rescission Request_20240614

FOR AGENCY USE ONLY
Assigned to: FRO
ARO FRO MRO RRO WARO WIRO WSRO
FQ
Division of Energy, Mineral, and Land Resources Land Quality Section ✓pyrg
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 lega�panizaje al ti Le ly respon le person ned in I m(4)below:
Street ad ress: C Stat a d ip co e:
Telepho number: Email address:
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2. Industrial Facility(facility requesting rescission):
Facility name: () G) 1 0- j
/ e
Scree d rest' Kr 9 l J 1 �✓
City: State: Zip Code' County:
-8 S- e .(i, 0�70�
Permit Number to which this request applies:
3. Reason for rescission Request /`/ C• V/J
This ispequired information.Attach separate sheets if necessary.
acility is closed or closing.All industrial activities have ceased such that no discharges of stormwater are contaminated
by exposure to industrial activities or matey als.
Date closed/closing:
Facility sold.
Sold to:
On date:
I3 Other(please explain):

4—Applicant Certification:
North Carolina General Statute 143-215.60(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($30,000).1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law,I certify that:
LJ 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: �I. � -
Title )rJo I j�✓�� V� �J JV
(Signature of Applicant) (Date Signed)
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Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental QuahtV i;4
1612-Mail Service Center ' s
Raleigh,NC 27699-1612
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