NCG070028_Rescission Request_20180831

Environmental
Quality
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 Dav
Please fill out and return this form if you no longer need to maintain your NPDES stormwater
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I SI N I C I G 10 17 10 10 2 8
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Metromont Corp. - Charlotte Facility
Facility Contact
Street Address
City
County
Telephone No.
Shane Simmons
4101 Greensboro Street
Charlotte
Mecklenburg
864 706-3550
State NC
E-mail Address
Fax:
ZIP Code 28206-2039
[e-mail]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
�qniQ'4bp
❑✓ Facility closed or is closing on 8-24-18 . 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 his request and to the best of my knowledge and belief
such information is true, complete and accurate.
Signature Date
Chuck Gantt Vice President & GM -Greenville, Charlotte, Spartanburg
Print or type name of person signing above
Title
Please return this completed rescission request form to: DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10 M