NCG080635_Rescission Request_20180725

ZI A—R-0
FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormvsater Permitting Program Year Month Day
National Pollutant Discharge Elimination System ����
Environmental IVC D
Quality RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES stormwater perm&ENR-LAND QUALITY
STORMWgTER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
Iv I c I S N I c I G 10 18 10 6 3 5
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name FedEx Freight, Inc. r �t L, !, h/
Facility Contact
Street Address
City
County
Telephone No.
Brenden Rose 7 7 W % (} t— I i VAS L/
2200 Forward Drive, DC:2219
Harrison
Boone
870 365-4087
State AR
E-mail Address
Fax: 901
`Facility Address: 177 West Forlines Rd, Winterville, NC 28590
ZIP Code 72601
492-2384
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 7/16/18 . 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 i e, co plete ' accurate.
Signature Date 7/1 7118
gree den /yse_ 6i ✓. -P
Print or type name of person signing above Title
Please return this completed rescission request form to
Revised 2018Jan10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612