NCG210211_Rescission Request_20170719

FOR AGENCY USE ONLY
A14 • Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
NCDENRNational Pollutant Discharge Elimination System
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
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)
N C 5
2) Owner/Facility Information:
Owner/Facility Name
Facility Contact
Street Address
City
County
Telephone No.
Certificate of Coverage
* Final correspondence will be mailed to the address noted below
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
. C**. -J
stormwater are contaminated by exposure to industrial activities or materials.
Facility sold to� k. Lkm►/ — ona e "reqaf �,pt�. If the facility will continue operations under the new owner it
may be more approprie�t an ownership change to reissue to permit to the new owner.
❑ Other:
4) Certification:
JUL 2 v 2017
I, as an authorized representative, hereby request rescission of coverage under the N������C'Permit for the
subject facility. I am familiar with the information contained in this request and tST� I�gi►�'e and belief
such information is true, complete and accurate.
A r-
Signature « Date
Print or type name of person signing above Title
Please return this completed rescission request form to: 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; r�,��~''
Phone. [phone] FAX, 919-807-6492 4 G�
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An Equal Opportunity 1 Affirmative Action Employer '�� '