NCG060276_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
RECEIVE�
(21" ilfo" RESCISSION REQUEST FORM OC7W 2 2 201b
Please fill out and return this form if you no longer need to maintain your NPDES stormwat46 j ATER PERMITTING
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 I N I C I G I d 3 1 V ?
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name l/,
Facility Contact
Street Address
City
County
Telephone No.
W
State ZIP Codef
E-mail Address ✓�f%/��n��' �i�E�J���'rr�6v'r���'I
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: 95,
77
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 informatio true, complealurate.
Signature .e l r 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
flail Service Center
h, North Carolina 27699-1612
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