NCG030306 Rescission Request

Please fill out and return this form if you no longer need to maintain your NPDES sstormwater permit.
1) Enter the permit number to which this request applies: ;qC6-0 o
Individual Permit (or) Certificate of Coverage
N: 1 C S N, C d. 0 13 10 10 0 0
2) Owner/Facility information: '" Final correspondence will be moiled to the address noted below
Owner/Facility Name Jacobsen A Textron Company
Facility Contact Virgil Yancey
Street Address 1451 Marvin Gr[ffin RD
City Augusta State GA ZIP Code 30906
County Richmond E-mail Address [e-mail]
Telephone No. [phone] Fax: [phone]
3) Reason for rescission request (This is -MulMd information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 2/16/18 . 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 v Wv Date 215118
Virgil Yancey EH5 Manager
Print or type name of person signing above Title
Please return this completed rescission request form to:
Revised 20183an10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
2@21MI
5 2018