NCG140207 Rescission Request

&VM;'1W]FA FOR AGENCY USE ONLY
•A Division of Energy, Mineral & Land Resources Date Rewived
Land Quality Section/Stormwater Permitting Program Year Month Day
NCDENRNational Pollutant Discharge Elimination System
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RESCISSION REQUEST FORM RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. MAR 15 2N
1) Enter the permit number to which this request applies: DENIR-LAND QUALITY
Individual Permit (or) Certificate of Coverage STORMWATER PERMaTiNG
N C 5 N G G) ,.
2) Owner/Facility Information; P Final correspondence will be mailed to the address noted below
Owner/Facility Name CC-- YY\ -E '7(- C1lt-\!7� C+tU o ,'} k -<y Q_ i,5 LL C
Facility Contact _ Ej C, tr
Street Address `_,'4oQ '� rr„-.t-h AA v-\ 4 �-
city 11 r,c t: State`�— ZIP Code 99 t ptf
County 0Z n, pn _ E-mail Address
Telephone No. -' . 5 -1 L3 Fax:
3) Reason for rescission request (This is Mullred Mullinformation. Attach separate sheet if necessary):
FacilitAlosed closedr is closing on ; , All industrial activities have ceased such that no discharges of
storrnwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to on If the facility will continue operations under the new owner- FRI
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. T 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.
Y' Y- CL
Print or type name of person signing above
Date
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 f0ail Service Center; Raleigh, North Carolina 27699-1612
Phone' 919-807-6300 l FAX: [phone] f ,
An Equal Opportunity 4 Affirmative Action Employer + f/t(( ' v (A
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