NCGNE0687_Rescission Request_20180817

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
N
Land Quality Section/Stormwater Permitting Program Year Month Da
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 N I c I G INEO 16 18 17
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Omnisource
Facility Contact
Street Address
City
County
Telephone No.
James Winegar
2233 Wal -Pat Rd
Smithfeidl
Johnston
919 989-3102
State NC
E-mail Address
Fax:
ZIP Code 27577
[e-mail]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 2012 . 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 Date
Z Jam9x`WneKr Environmental Manager
me 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 27T;9E'VE®
/.JG i ; 2018
D QUALI t I
Revised 2018Jan10�� ;,jv WERPERMITTING