NCG130062_Rescission Request_20170313

FOR AGENCY U9E ONLY
M Division or Energy, Mineral &Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month oay
NCDENR National Pollutant Discharge Elimination System
NanN C.wOIN.I O[xagL,.zMOI
EYVNOM,nEVr trN NNWK FGWNCCS
RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES Stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C S
2) Owner/Facility information: • Final correspondence will be mailed to the address noted below
Owner/Facility Name C0-ro'�c+_ V.-,,_ .
Facility Contact
Street Address
City
County
Telephone No.
'4Qt SVk nvkC (2-"� A
State _IJ e ZIP Code -29 c9 k
E-mail Address ; h r - c Ah+e o ,,p ,
Fax:
3) -Reason for rescission request (This is required information. Attach separate sheet if necessary):
5 Facility closed or is closing on 3%t If -+. All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to on . If the facility will continue operations under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
❑ Other:
4) Certification:
I, as an authorized representative, hereby request rescission 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.
Signatl
I Im K tc
Print or type name of person signing above
Date 3 t
����Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
An Equal Opportunity i Affirmative Action Employer
MAR 13 2017
V�
rl
State _IJ e ZIP Code -29 c9 k
E-mail Address ; h r - c Ah+e o ,,p ,
Fax:
3) -Reason for rescission request (This is required information. Attach separate sheet if necessary):
5 Facility closed or is closing on 3%t If -+. All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to on . If the facility will continue operations under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
❑ Other:
4) Certification:
I, as an authorized representative, hereby request rescission 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.
Signatl
I Im K tc
Print or type name of person signing above
Date 3 t
����Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
An Equal Opportunity i Affirmative Action Employer
MAR 13 2017