NCGNE1090_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
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
Iv I c I S I I I I N c c N E 1 0 9 0
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Westrock Company
Facility Contact
Street Address
City
County
Telephone No.
Bonnie Mathis
376 Pine Street
Forest City
Rutherford
828 248-4958
State N.C.
E-mail Address
Fax:
ZIP Code 28043
bon nie. [e-mail]
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
may be more appropriate to request an ownership change to reissue to permit to the new owner.
❑✓ Other: Our company ended it's lease with the owner, discontinuing use of this building as a warehouse, located at 141 Duke Street,
Forest City, N.C. 28043.
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
�5
Bonnie Mathis
Print or type name of person signing above
Please return this completed rescission request form to
Date 12/03/2018
Safety Manager
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-161'REC 1= i\/r—
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Revised 20183an10 DENR-LAND QUALITY
STORMWATER PERMITTING