NCG110154 Rescission Request

Environmental
Quality
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 Month pay
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Please fill out and return this form if you no longer need to maintain your NPDES stormwater per itZ6m
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1) Enter the permit number to which this request applies: .RMl7 ]j�G
Individual Permit for) Certificate of Coverage
N I C I S I I I I I I I N I C G 1 j 1 0 1
Z) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name,-' of airrohu wRs�e(dr:�r
Facility Contact
Street Address
City
County
Telephone No.
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Sa 3- 9 3-7 r sz3s
State SVG ZIP Code ;2,?fVy
E-mail Address
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
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to
on . If the facilitywill continue operaticns under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
Other: ce Vc,%,, �L 5Amc 5- rmwwe.,r deck h
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4) Certification:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Pe -mit 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
PP 7-,0 �!€
Print or type name of person signing above Title
Please return this completed rescission request form to
Revised 20183an10
DEML.R - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612