NCG070004_Rescission Request_20190211

( FOR AGENCY USE ONLY
Division of Finergy, Mineral & Land Resources Date Received
1 Land Quality Section/Stormwater Permitting Program i Year Month Day
g
National Pollutant Discharge Elimination System
En vircm menta
Quality RESCISSION REQUEST FORM";'
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: DENR LAND QUALITY
Individual Permit (or) Certificate of Coverage
STCRM.W" Erg PEI"Slvil 111NO
N C G 0 7 10 0 �0141
2) Owner/Facility Information: • Final correspondence will be mailed to the address noted below
Owner/Facility Name Jason Inc - Jackson Lea
Facility Contact
Street Address
City
County
Telephone No.
Jim DeSonia
1715 Conover Blvd East
Conover State NC
Catawba E-mail Address
414 212-2215 Fax:
ZIP Code 28613
jdesonia@jasoninc com
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:
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, co e and ac orate.
Signature% Date
im DeSonia Vice President - EH&S
Print or type name of person signing above Title
Please return this completed rescission request form to
Revised 20181an10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612