NCG050007_Rescission Request_20180423

Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) I=nter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I 5 N:C I. sb5'G0'0
2) Owner/Facility Information: Final correspondence will be mailed to the address noted below nn -4
' 1 r� `�
Owner/Facility Name 11 P_ / "r,�'� ,,,�1- ' � . r f , c
Facility Contact uc_ -'
Street Address d� Civ j
City State .ZIP Cod
2
County r E-mail Address a� V, c�
Telephone No. I TO tl %. 1- t'{ 13 0 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on . All industrial activities have ceased such that no discharges of
f G o vt
stormwater are contaminated by exposure to industrial activities or materials.
Facility sold to I�Se_v+�fw on 26.E 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
yq �'
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
�CEIVEo Raleigh, North Carolina 27699--1612
APR 2 $ 2018 1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
DENRUNDVP
S M TER E I� An Equal Opportunity 1Affirmative Action Employer
FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources
Date Received
Land Quality Section/Stormwater Permitting Program
Year Month Day
NCDENRNational
Pollutant Discharge Elimination Systern
Noniei CSR 1- of
ENVIROHMewr nno N4TURLL R- ­
RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) I=nter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I 5 N:C I. sb5'G0'0
2) Owner/Facility Information: Final correspondence will be mailed to the address noted below nn -4
' 1 r� `�
Owner/Facility Name 11 P_ / "r,�'� ,,,�1- ' � . r f , c
Facility Contact uc_ -'
Street Address d� Civ j
City State .ZIP Cod
2
County r E-mail Address a� V, c�
Telephone No. I TO tl %. 1- t'{ 13 0 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on . All industrial activities have ceased such that no discharges of
f G o vt
stormwater are contaminated by exposure to industrial activities or materials.
Facility sold to I�Se_v+�fw on 26.E 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
yq �'
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
�CEIVEo Raleigh, North Carolina 27699--1612
APR 2 $ 2018 1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
DENRUNDVP
S M TER E I� An Equal Opportunity 1Affirmative Action Employer