NCG210203_Rescission Request_20180830

FOR AGENCY USE ONLY
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- - Division of Energy, Mineral &Land Resources Date Received
p' Year MonthDay
„x Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
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Qualky 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 C S N C G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facilit Name SE�OK-PT!�(� '� ' X ► ..--IV
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Facility Contact -A C-� G'G't 1�
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Street Address '5- -A Ar.1
City e, r tj �+- & r1
County co i aA b
Telephone No. A to 4- L i - 7 L as.=
State IV C
E-mail Address
Fax:
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ZIP Code
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
Facility closed or is closing on 4 J APO � . 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:
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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 g Date
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Print or type name of person signing above Title
Please return this completed rescission request form to:
Revised 2018Jan10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
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