NCG020417 -Rescission Request

FOR AGENCY USE ONLY
} , Division of Energy, Mineral & Land Resources Date Received
ti Vand Quality SectioniStormwnter Permitting Program Year Month Da
rt" " Naitional:Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
Please FII out and returnAhis 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 I I I I I I I I N I C I G lolRlol4l
i) Owner/Facility Information: ° Phial correspondence will be mailed to the address note4 below
Owner/Facility Wuwt Ulaj
ele%dt Gai
Facility Contact L—e-kirnak d5TASOJAt
Street Address 141D S
City 14 State Ate— ZIP Code
County J?; E-mail Address ea �eS-4e Sr �t ��_,_
Telephone No. p1Q�-'-L Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
acility, closed or is closing on S . 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.
❑ Otheri"
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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'.Signature !. ,.1--�-�- c� �� �Date l 1 3 1 f
Print or type name of person signi4 sign"above Title
''Tease return this completed rescission request form to: DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Im"ECEIV5D
FEB 13 2019
Revised 20183ani0 DENR-LAND QUALITY
STORMWATER PERMITTING