NCG090030_Rescission Request_20180727

FORAGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
N
' Land Quality Section/Stormwater Permittirg Program Year Month Da
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
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
Iv I C I s I I I I I N C T KKFO
2) Owner/Facility Information: Final correspondence will be moiled to the address noted below
Owner/Facility NameSiegwerk EIC LLC
Facility Contact
Street Address
City
County
Telephone No.
Robert Miller HSE or Chad Davis PM
950 Craftsman Drive
Morganton State NC ZIP Code 28655
Burke E-mail Address [e-mail]
828 391-2314
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 facility will continue operations under .he new owner it
may be more appropriate to request an ownership change to reissie to permit to the new owner.
✓❑ Other: NEC status applied for, Inspection for NEC to take place on 8-7-2018 per Isaiah Reed
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
Robert Miller
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 20183an10
Date 7-24-2138
HSE Coordinator
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center S DF
Raleigh, Nor --h Carolina 27699!y4t� 4 1 DQ o'7