NCG210027_Rescission Request_20171206

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Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Dara Reeervetl
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Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. 6 c
1) Enter the permit number to which this request applies: � 0
Individual Permit (or) Certificate of Coverage m
C= N I C I G<1 2 1 1 1 0 0 2 17
2) Owner/Facility Information: " Final correspondence will be mailed to the address noted below
Owner/Facility Name Dimension Wood Products, Inc.
Facility Contact David Reinhardt
Street Address 2884 Kelly Blvd , pa Box ICi
City Claremont State NC ZIP Code 28610
County Catawba E-mail Address [e-mail]
Telephone No. 828 459-9891 Fax: [phone]
3) Reason for rescission request (This is reguired information. Attach separate sheet if necessary):
❑ Facility closed or is closing on IM . All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to MINJIM on MW . 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: All industrial oils, chemicals, & materials are stored indoors or under a storm resistant
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shelter (with secondary containment & tops on containers).
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 �Q Li Afi!6D Date 11/29/2017
David Reinhardt President
Print or type name of person signing above 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 c
1612 Mail Service Center, Raleigh, North Carolina 27699-1612 RECEIVE[)
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Phone: [phone] FAX: [phone] DEC 62017
An Equal Opportunity l Affirmative Action Employer DENR-LAND 1I
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