NCGNE0031_Rescission Request_20180905

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources KDate Received
Land Quality Section/Stormwater Permitting Program Year Month Da
National Pollutant Discharge Elimination System
Environmental A
Quality RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.. O ����0 ��
1) Enter the permit number to which this request applies: Gliq>C9�0 OJT
Individual Permit (or) Certificate of Coverage
N I C I S Iv I t I s IN E 10 10 3 11 1
T�'tic
2) Owner/Facility Information: * Final correspondence will be moiled to the address noted below
Owner/Facility Name Reliance Electric Ind. Co (Dodge Rockwell Automation)
Facility Contact
Street Address
City
County
Telephone No.
Corbin Overstreet
510 Rockwell Dr.
Marion
McDowell
828 655-3963
State NC ZIP Code 28752
E-mail Address [e-mail]
Fax: [phone]
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: It appears that a duplicate no exposure exclusion was activated (NCGNE0465). We have since gone
through two ownership changes, and NCGNE0465 was appropriately self -certified annually, latest date of 8/3/18.
1 was unaware of NCGNE0031 until the state inspector brought it to my attention yesterday, so it has not been certified annually.
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 C_�CSZ/w Date 8/31/2018
Corbin Overstreet Environmental Coordinator
Print or type name of person signing above
Please return this completed rescission request form to
Revised 20183an10
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612