NCGNE0216_Rescission Request_20180727

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FOR AGENCY USE ONLY
• Division of Energy, lfineral & Land Resources Date Received
r Da Land Quality Section/Stormwater Permitting Program Year Month
NCI��y
..D��'ENR National Pollutant Discharge Elimination System
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RESCISSION REQUEST FORM ,
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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
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-----2)--0wner/Facil1ty Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name LEro6e,Tf f' P "4 --Tr 6 t=tcl e e e -&m Py"Ed TS z L L G
Facility_ Contact PA -VSE
Street Address 330 N, GReFAIS&ORD ST.
City L he F2TY State NG ZIP Code 27 7_4 0
County 12AW,15 OL 104 E-mail Address
Telephone No. 33 (o (0 22 - D ! 2 / Fax: 33 (o
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on fFMI, . All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to .„_.....n. `M 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: SIG 406-16 COW6 p TO 9009, N0 FWA*SVQ, ND
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
'rnris true, complete and accurate.
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SignatureDate
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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
RECEIVED Raleigh, North Carolina 27699-1612
!! ; 0 5 2018 1612 Mail Service Center, Raleigh, North Carolina 27699-1612,
Phone: [phone] FAX: [phone]
DENR-LAND QUALITY An Equal Opportunity 1 Affirmative Action Employer
STORMWATER PERMITTING