NCGNE0211_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
I Day
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
DENR-LAND QUALITY
11 Enter the ermit numb r to h' h th' t I'
STORI'•� ATM EiR PEWA' i TING
p e w is is reques app ies.
��Individual Permit (or) Certificate of Coverage
'I "ICISI I I� —F I N G I n1 Z--Jo 1 ;2_) 1
2) Owner/Facility Information: ' Final correspondence will be mailed to the address noted Ibelow
Owner/Facility Name
i
Facility Contact
Street Address
City
County
Telephone No.
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
21 /Facility closed or is closing on 11.&ALI 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 thic renuPct and to the heof rr y knnWhnrinR and hPrpf
such information is true, plete an a curate.
Signature Date AZ// L�
Print or type named person signing above Title
Please return this completed rescission request form to:
Revised 20183an10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612