NCGNE0941 Rescission Request

FOR AGENCY USE ONLY
as
Division of Energy, Mineral & Land Resources Y Date Received
AA74AN ;� Land Quality Section/Stormwater Permitting Program ear Month Day
NCDENRNational Pollutant Discharge Elimination System
NTANNURAL
EN`/IFONMENT AND NArLrRPL RESOIIRGES
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 S N I C G N E 0 9 4 1
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name National Express LLC
Facility Contact Bettylurkowski
Street Address 2601 Navistar Drive
City Lisle A State IL ZIP Code 60532
County Dupage tTLkI _ E-mail Address [e-mail]
Telephone No. 630 821-9058 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
0 Facility closed or is closing on 11/30/2017A11 industrial activities have ceased such that no discharges of
Stormwater are contaminated by exposure to industrial activities or materials.
El 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
Betty Iurk s
Print or type name of person signing above
Please return this completed rescission request form to
Date
3/9/2018
Sr, Environmental Compliance Manager
Title
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] ti FAX: [phone]
An Equal Opportunity l Affirmative Action Employer
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