NCG120073 Rescission Request

FOR AGENCY USE ONLY
Division of Energy, Mineral & land Resources Dale Received
Year Month Day
Land Quality Section/Stormwater Permitting Program
NCDENRNational Pollutant Discharge Elimination System
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cM �t«,.. N.KNR�s«K. RESCISSION REQUEST FORM �Le
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Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. 0 7 2018
STD ENR -LAND QUALITY
1) Enter the permit number to which this request applies: RMWATER PERMITTING
Individual Permit (or)
(or) C(er�tif(icate of Coverage
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2) Owner/Facility information: "Final correspondence will be mailed to the address noted below
Owner/Facility Names (CIVAQ
Facility Contact :) c ' J(1, r
Street Address P.o. i5ose�3a
City c. State N C. ZIP Coded'
County A V_ E-mail Address
Telephone No. 33L7 94k Fax: 33Co SCI& � f
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, 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.
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4) Certification: Neq se { f P 1
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_4rue, complete and accurate.
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Print or type name of pkson signing above
Date 4L h 4
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Title
Piease 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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