NCGNE0948 Rescission Request

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 System VE
No- CAROLINA DEP RTMENT OF e3 2011
I D
ENVIRONMENT AND NATURAL RESOURCES RESCISSION REQUEST FORM JAN
Please fill out and return this form if you no longer need to maintain your NPDES stormwater �1r gTFR p u'ql N
1) Enter the permit number to which this request applies: G
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I I I I N I C I G N 16 O? c{ g
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Q O A Jo V 5, S#IJ c.
Facility Contact E (2l C H 9 y I&K E
Street Address -7 G 1. 5 T I -to A rJ P 1 V E R
City 4 R EEIuS B or? o State NL ZIP Code '-"7 yo9
County l U LFoRD E-mail Address ER►cH g V Ri:C- @ 004v0. c-0"
Telephone No. 3 3 (0 93 1- G o YA Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
12 Facility closed or is closing on '17 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
S'tt•1e (3¢aa 112GCTX.A orACtct-rie5
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 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
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