NCG030282_Rescission Request_20181022

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System RECEIVED
t"slid ' RESCISSION REQUEST FORM oc7W 2 2 201b
DENR-LAND QUALITY fill out and return this form if you no longer need to maintain your NPDES stormwatEgM*ATERPERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I I I l"1 G I d 3 V Z �
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name l/,- _:;?­it/Gr
Facility Contact
Street Address
City State ZIP Code
County E-mail Address ✓/�f/�o�/ L�E���l �r.,>��
Telephone No. Fax:
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
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
m be more appropriate to request an ownership change to reissue to permit to the new owner.
Other: eg7,� 77Zn/—D-��7n
L /"I c f/: A-' —A:;'
4) Certification:
t
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 informatio rue, complete and accurate.
�� r �X�
Signature /J t , Date
Print or type name of person signing above Title
Please return this completed rescission request form to:
Karen Brooks
Office/Purchasing Manager
Appalachian Tool & Machine Inc.
828-669-0142
We've Moved Please Note our NEW Address
121 Lytle Cove road, Swannanoa NC 28778
DEMLR - Stormwater Program
Dept. of Environmental Quality
Mail Service Center
h, North Carolina 27699-1612