NCG140205 Rescission Request

Environmental
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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
Date Received
Year J Month Day
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Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. DENp - 11
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1) Enter the permit number to which this request applies: 'gI
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Individual Permit (or) Certificate of Coverage
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2) Owner/Facility Information: "Final correspondence will be mailed to the address noted below
Owner/Facility Name Co L4 ("A � vPC 0,14 LC C - rl0f-: c . 4opn
Facility Contact
Street Address
City
County
Telephone No.
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State PC _
E-mail Address
Fax: 7u-1
ZIP Code a7"-5� __
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3'3Lr- 4r4,170
3) Reason for rescission request (This its required information. Attach separate sheet if necessary):
[Facility closed or is closing on 11e1 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 Date
0404t It f�+u�roHnr."kl /"7t �•rti.c.� ---
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