NCG080956_Rescission Request_20190221

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
" National Pollutant Discharge Elimination System
Fnvironment'al
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
I Month
I 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)
N C S
Certificate of Coverage
N c G 0 8 0 9 5 6
2) OWneY/FeLlllty InfOrmatlOn: * Flnol correspondence will be ma(led to the address noted below
Owner/Facility Name Quality Carriers, Inc.
Facility Contact
Street Address
City
County
Telephone No.
Shawn Lawrence
3823 Hawkins Ave
Sanford
Lee
[phone]
State NC ZIP Code 27330
E-mall Address [e-mail]
Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 2/1119 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, complete
rue,compllete and accurate.,
JSignature A �`� ✓ �� Date 2/22/2019
Danielle Kruichak
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 2018Jan10
Environmental
Title
DEMLR -Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612