NCG080149_Rescission Request Form_20180814

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Da
Kc. 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
N I C I S I I I I I I I I N I C I G 1 O Q a 1
2) Owner/Facility Information: • Final correspondence will be moikd to the address noted below
Owner/Facility Name 1J cz:�Rr- �3 �►L .0 —
Facility Contact
Street Address
City
County
Telephone No.
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
14 Facility closed of is-slesft-en- . 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.
4) Certification:
,oi,t5"
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/s—t-rdV, complete aqd accurate.
Signature
Print dr type name of person signing above
. I i o i.
V A! ..
Please return this completed rescission request form to: DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 276�9,9MED
AUG 14 2018
Revised 20181an10 DENR-LAND QUALITY
STORMWATER PERMITTING