NCG030028_Rescission Request_20180207

FOR AGENCY USE ONLY
�`� • Division of Energy, Mineral & Land Resources Date Received
�r Land Quality Section/Stormwater Permitting Program Year I Month Da
RCDENRNational Pollutant Discharge Elimination System
NORM CAROLINA DEPARTMENT OF
ENVIRONMENT ANO NATURAL RCSOURCCS
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 I C I S N I C I G 1 0 1 3 1 0 1 0 1 2 1 8
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Na
Facility Contact
Street Address
City
County
Telephone No.
Minuteman Powerboss Incorporated
j �wti. &A
14N845 U.S. Route 20
Pinaree Grove State IL
KANE
847 264-5400
ZIP Code 60140
E-mail Address kamp.q@rninuti2manin!l.com
Fax: [phone]
3) Reason for rescission request (This is reguired 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: Minuteman Powerboss Inc has ended its industrial activities in Aberdeen, NC as of 8/31/2016 when its lease ended at
this location. 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.
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.
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Print or type name of person signing above
Date
Sr,
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 \ Affirmative Action Employer