NCG100155

TON* 71 EOR AGENCY USE ONLY
• . Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
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NCDEf����NR National Pollutant Discharge Elimination System R CE IV- D
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EWIRoxNert ON: unA 111.C" RESCISSION REQUEST FORM NOV —3 2017
Please fill out and return this form if you no longer need to maintain your NPi3ES Stormwater permit:-
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S e_ 1 & I ' I N I C 1 G
2) Owner/Facility Information: " Final correspondence will be mailed to—�the address noted below
Owner/Facility Name'
Facility Contact
Street Address
City rVyzq N[, 7 77 State 1,7i
f—,
E-mail Address
Telephone No. Fax:
ZIP Code 1�-7 70
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on . 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.
Signature
Print or type name of person signing above
Date 14�
dbilly ig
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
1692 Mail Service Center, Raeigh, North Carolina 27699-1612
Phone: [phone] l FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer �p