NCG100142_Rescission Request_20190211

Environmental
Quality
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
02C, 0 r L'%� O1I ti3
vw f
u'ENR-LANs? QUAL IT`(
Please fill out and return this form if you no longer need to maintain your NPDES stormwater p)?M' PErttvii i 'ii
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C S N C I G' (:)I(:) I
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/ Facility Name �� i, �-� i, 'V.\
Facility Contact
Street Address `' 4 C) T..
City l6j,t-4 Ld State ZIP Code Z u
County i I V �S E-mail Address m�..
Telephone No. q t� i) i 7 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
El Facility closed or is closing or�J'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.
el
Signature Date ' `rt � 0
Print or type name of person signing above Title
Please return this completed rescission request form to:
Revised 2018]an10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612