NCG180252_Rescission Request_20190211

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Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Environmental
Quality RESCISSION REQUEST FORM RECEI1 jEirp
Please fill out and return this form if you no longer need to maintain your NPDES stormwater PWW.l 4 2018
1) Enter the permit number to which this request applies: DENR`LAND QUALITY
Individual Permit (or) Certificate of Co era WATER PERMITTING
N C I S N I C I G 11 18 10 2 5 2
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Heritage Home Group, LLC, Morrison Avenue Distribution Center
Facility Contact
Street Address
City
County
Telephone No.
David Stout - Director of Environmental Compliance
Owner Mailing address: 815 Visionary Street, Lenoir NC 28645
Lenoir
Caldwell
828 759-8510
State NC
E-mail Address
Fax: N/A
ZIP Code 28645
[e-mail]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 11/2/18 . 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
The building is leased from John and Jeff Schwarz, LLC of 585 Cross Creek Tri, Gibsonville, NC27249, phone [phone]
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 Date 11/8/18
David Stout Director of Environmental Compliance
Print or type name of person signing above
Please return this completed rescission request form to:
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10