NCGNE0522_Rescission_20190206

Division of Energy, Minerill & Land Resoure"
Lana Q11"llity Section/Stormwatel- Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year I Month Day
RECEIVED
Please fill out and return this farm if you no longer need to maintain your NPDES stormwater permit, FEB 0 6 2019
1) Enter the permit number to which this request applies:
Individual Permit (or)
N C 5 ] - . [''. , I I I
DENR-LAND QUALITY
Certificate of Coverage STORMWATER PERMITTING
EC"G ©�
2) Owner/Facility Information: * Final correspondence will be mmailed to the address noted below
Owner/Facility Name4EAVT
Facility Contact b C4TEH 9 X
Street Address ]-5e) �r�SSi
City L�cli£.R -
County ZASo) _
Telephone No. (,
61139
State C-- _ ZIP Code ag-)`J 2.
E-mailAddress
Fax: •r�}� y'(CTas�CZsFitiGor1
3) Reason for rescission requests {This is regpired 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
may be more appropriate to request an ownership change to reissue to permit to the new owner.
Other: L gN
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 k 1&hAm Date 11151 Print or type name of person sig ing above "title
Please return this completed rescission request form to:
East West Inc.
P.Q. Box 580 Fletclier NC, 28732
1-800-228-1543
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center Received
Raleigh, North Carolina 27699-1612
JAN 18 2019
Revised 20183an10 Land QuEllity Seition
Asheville