NCG030567 Rescission Request

FOR AGENCY USE ONLY
0701 ■� Division of Energy, Mineral & Land Resources Date Received
r Land Quality Section/Stormwater Permitting Program Year Month Da
NCDENRNational Pollutant Discharge Elimination System
Mpzna vwouMn oe► arMerrr or
EM NCHME- AND NffURP RE"i ES
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 5 I I I I I I N I C I G
2) Owner/Facility Information: * Final correspondence will be maiied to the address noted below
Owner/Facility Name��
Facility Contact
Street Address `
City State 4f ZIP Code Zg
County E-mail Address
Telephone No. %05 - 3Ld 9 Fax:
3) Reason for rescission request (This is maLukred 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 V'Plt'I jgeS tr7G on - 3-7-J'9. 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 rr Date I�
IJov E'
C./ A
Print ar pe name of perso igning 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
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
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