Loading...
HomeMy WebLinkAboutNCG030129_Rescission Request JandJ Machine Works_20190213Division of Energy, Mineral & Land Resources Land Quality Section/Stormwater Permitting Program " National Pollutant Discharge Elimination System Environmental Quality RESCISSION REQUEST FORM FOR AGENCY USE ONLY Date Received Year Month Day RECF. I ED Please fill out and return this form if you no longer need to maintain your NPDES stormwater P912MLAND QUALITY STORMWATER PERMITTING 1) Enter the permit number to which this request applies: Individual Permit (or) Certificate of Coverage N I C I S I I I N C G () ,3 0 Z 2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below Owner/Facility Name L(J0 -3 tr_Rk Facility Contact C_Jg `L e3 %(fie () Street Address City v . r County —hAL) i� Telephone No. .336 "ems State IV6 ZIP Code E-mail Address Fax: 3) Reason for rescission request (This is required information. Attach separate sheet if necessary): — 0 t)1,6 Facility closed or is closing on 01 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: f, E�s an a uthr`rize-+ renrescntative 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 beiier such information is true, comple7d',a,rate. Signature � Date Print or typ name of person signing above Title Please return this completed rescission request form to Revised 2018Jan10 DEMLR - Stormwater Program Dept. of Environmental Quality 1612 Mail Service Center Raleigh, North Carolina 27699-1612