NCG200422_Rescission Request_20180413

FOR AGENCY USE ONLY
A*A • � Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month ❑ay
NC/.��D.ENR National Pollutant Discharge Elimination System
KORTf 4 CAROU" DF.Pa HEn �F
ENNRONMEl MD NRURI RESOURCES
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 C 5�N G � D a r-1 Z Z
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name 5" ons el,n ` 'eaj
Facility Contact '
Street Address WQ4I.5_1'Z,]b►ltaon I ck Cokr-r
City Cew I . State Ne ZIPCode 29Z'7'7
County Alec"e46ocE-mail Address �1)1 tl (a1 Z43< llc. Carl
Telephone No. R t_o LA 5 - gtn30 Fax: 9 fi a 9,)5- q&3 z
3) Reason for rescission request (This is renuired information. Attach separate sheet if necessary):
b���otfg
Facility closed or is closing on m������sAll industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to T 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 tr , complete an acc
Signature Date
L,),% I 1 S; A L> OL wrZ
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 27699-164 D '►`�
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1612 klail Service Center, Raleigh, North Carolina 27699-1612 TF OQ B
Phone: [phone] FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer