NCG080266_older Rescission Request_20180403

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Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
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National Pollutant Discharge Elimination Systeml(3 E
RESCISSION REQUEST FORM :r jJa
urrvN-LA D QUALITY
Please fill out and return this form if you no longer need to maintain your NPDES stormi0bitergo r� PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S 10 18 1 1 N I C I G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name RW T4-irrlrjnq CO Inc
Facility Contact Gary L Harold
Street Address 1772 N Andy Griffith Pkwv
City Mount Ai
County Surry
Telephone No. 330-J89-
State NC ZIP Code
E-mail Address Oaro
Fax: [phone]'
3) Reason for rescission request (his is required information. Attach separate sheet if necessary):
)G Facility closed or is closing o r� Tthf . 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.
Signaturelrt r�� Date +�J`l�
Gary(L/Harold Owner — 4�—.s t a�p-
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 1
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone] l
An Equal Opportunity 1 Affirmative Action Employer
Received
Year Month
Day
National Pollutant Discharge Elimination Systeml(3 E
RESCISSION REQUEST FORM :r jJa
urrvN-LA D QUALITY
Please fill out and return this form if you no longer need to maintain your NPDES stormi0bitergo r� PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S 10 18 1 1 N I C I G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name RW T4-irrlrjnq CO Inc
Facility Contact Gary L Harold
Street Address 1772 N Andy Griffith Pkwv
City Mount Ai
County Surry
Telephone No. 330-J89-
State NC ZIP Code
E-mail Address Oaro
Fax: [phone]'
3) Reason for rescission request (his is required information. Attach separate sheet if necessary):
)G Facility closed or is closing o r� Tthf . 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.
Signaturelrt r�� Date +�J`l�
Gary(L/Harold Owner — 4�—.s t a�p-
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 1
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone] l
An Equal Opportunity 1 Affirmative Action Employer