NCG080589_Rescission Request_20171016

FOR AGENCY USE ONLY ' I I x
00 Division of Energy, Mineral & Land Resources Date Received (q v
Land Quality Section/Stormwater Permitting Program Year Montn Da
r �
NCDENRNational Pollutant Discharge Elimination System
NO CMo Dews mM OF
Ewviaon — Na Reso,mces
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
0 1 8 1 0 5 8 9
2) Owner/Facility Information: • Final correspondence will be mailed to the address noted below
Owner/Facility Name Republic Services of North Carolina, LLC
Facility Contact
Street Address
City
County
Telephone No.
Matt Einsmann
5111 Chin Page Road
Durham
Durham
919 354-3227
State NC ZIP Code 27703
E-mail Address [e-mail]
Fax: 11 =_ E VE
3) Reason for rescission request (This is required information. Attach separate sheet if necessary): OCT zon
❑ Facility closed or is closing on All industrial activities have ceased such that no disch�rgt` I �'' 1 '_I-.Y� „
stormwater are contaminated by exposure to industrial activities or materials.
x❑ Facility sold to NallIdWes on 0M 7 . 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
✓ "lwtiti
Matt Einsmann
Print or type name of person signing above
Please return this completed rescission request form to:
Date
10/03/2017
Environmental Manager
Title
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: [phone]
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