NCG030254_Rescission Request SPG Prints_20190122

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
Quafltti' 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.
;VR-LAND QUALITY
0R9iA'y� S1 PERMIT T
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I N C I G 3 ,? 'f
2) Owner/Facility Information: *,Final correspondence will be mailed to the address noted below
Owner/Facility Name 5 Pd
Facility Contact .C(M d Ai`
Street Address Ro f 'V-2
City 9/6 /f State
County e cl(/e' E-mail Address
Telephone No. 22!J - 5?,Y -- e7 '7 / Fax:
ZIP Code
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:
1, as an authorized representative, hereby request rescission of coverage under the NPDES Stormiwater 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, c plete and accurate.
Signature Date
�ZX�rj
,�
,J r0d q r-
Print or type name of person signing above
Please return this completed rescission request form to:
60hd,`V,4-A)f
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10