NCGNE1231_RescissionRequest_20180423

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
N
' Land Quality Section/Storm water Permitting Program Year Month Day
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
Iv I c I s I I I I I I I I N I C I G IN JE 11 12 13 11
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name L3 Technologies, Inc.
Facility Contact
Street Address
City
County
Telephone No.
Justin Vacca
7650 Omnitech Place
Victor State NY
Monroe E-mail Address
585 742-9602 Fax: 585
ZIP Code 14564
[e-mail]
742-5469
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 3/30/18 . 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 this request and to the best of my knowledge and belief
such information is true, complete and accurate.
Signature
Vacca
Print or type name of person signing above
Please return this completed rescission request form to
RECEIVED
APR 2 3 2018
DENR-LAND QUALITY
fiTORMWATER PERMITTING
Revised 2018Jan10
Date 3/29/2018
Sr. Manufacturing Engineer, Facilities Lead
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612