NCGNE1023 Rescission Request

A U -STA TE BELTING ift
NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, NC 27699-1612
RE: Rescission Request — All -State Belting, LLC.
•.s
rAeC)
All -State Belting, LLC.
520 South 18'" Street Toll Free: 844-566-2358
West Des Moines, IA Phone: [phone]
50265-5532 Fax: [phone]
t -cd 1.4 2017
Enclosed please find a Rescission Requestform for No -Exposure certificate NCGNE0123 issued to All -
State Belting, LLC. Certificate NCGNEQ123 is currently in effect for All -State Belting's operations located
at: ��
All -State Belting, LLC.
1400 Westinghouse Blvd.
Suite 100
Charlotte, NC 28273
All -State Belting's operation at the Charlotte address will cease on or about March 31, 2017 and the
assets at this location will be relocated outside of the state of North Carolina. Please accept the enclosed
rescission form as notice for cancellation of All -State Belting's No -Exposure Certification at the above
listed address, as of March 31, 2017. Any requests for additional information and/or notice of final
rescission should be sent to All -State Belting's corporate address in Iowa, as listed on the rescission
form.
Regards,
Alex Ward
All -State Belting, LLC.

NCDENR
Np - CAP.L DEP .ENT OF
ENviRONN AND NCRIRK RE -ES
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year Month Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
, o 14 2017
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 N I C I G I N I E 1 0 1 1 1 2 1 3
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below_y
Owner/Facility Name ALL -STATE BELTING, LLC.
Facility Contact
Street Address
City
County
Telephone No.
ALEX WARD
520 SOUTH 18TH STREET
WEST DES MOINES
POLK
515 645-6955
State IA
E-mail Address
Fax: 515
ZIP Code 50265
AWARD @ ALL -STATE BELTI NG.COM
224-1169
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑■ Facility closed or is closing on 3/31/2017 . 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 is true, complete and accurate.
Signature �1� Date
DAVID CLARK TREASURER/CONTROLLER
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
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] \ FAX: 91M07-6492
An Equal Opportunity \ Affirmative Action Employer