NCG060362_RescissionRequest_20180824

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
N
a Year Month Day
Land Quality Section/Stormwater Permitting Program
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 N I C I G 0 6 0 3 6 2
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Nash Johnson and Sons Inc. Grain Elevator
Facility Contact Chris Murray
Street Address 1252 US Highway 117 South
City Warsaw State NC ZIP Code 28398
County Duplin E-mail Address [e-mail]
Telephone No. 910 990-7921 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 the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
✓❑ Other: This property has been determined to have no -exposure to storm water.
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 tr , complete and accurate.
Signature Date ZZ
Print or type name of person signing above Title
Please return this completed rescission request form to:
Revised 20183an10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
RECEIVED
AUG 2 4 2018
DENS -LAND QUALITY
STORMU11AfER PERMITTIN
WZ W