NCG050032 Rescission Request

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FOR AGENCY USE OWY
a" Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program
Year Month Day
National Pollutant Discharge Fliminaticm System
Environmental
Quality RESCISSION REQUEST FORMVP r
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permitf ut2Q
18
1) Enter the permit number to which this request applies: rQR j�W BIND Q(J
Individual Permit (or) Certificate of Coverage RrFRp�R4f" TY
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N I C S N I C I G Ci 15 63 16 :3
2) Owner/Facility Information: ' Final correspondence will be mailed to the address noted below
Owner/Facility Name 11 TL4-S Petczs� N
Facility Contact J6,6c_ nl , .56um-t3
Street Address
City
County
Telephone No.
oleolx_
40
state 4,, -
E-msil Address
Fax:
ZIP Code -2976
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 facility ,will continue operations under the new owner it
�/ may be more appropriate to request an ownership change tc reissue to permit to the new owner.
B Other: h4dI /ve—'C70 C 033-2 -Nr3 6 n,mct l� C�!C-jctSeczlV
4) Certification:
I, as an authorized representative, hereby request rescission of cove -age ander 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'
CEL tb
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 2018Jan10
Date
-7-d3-.201<�
/7/i' lvdthanee Jirgictgp!
Title
DEMLR - Stormwater Program
Dept. of Envronmental Quality
1612 MGil Service Center
Raleigh, Norh Carolina 27699-1612