NCG030633_Rescission Request_20190314

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
Day
RF.rFIVFD
Please fill out and return this form if you no longer need to maintain your NPDES stormwater pR. 14 2019
1) Enter the permit number to which this request applies: DENR-LAND QUALITY
STORMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N I c I s I I I I I I I N I C I G 10 13 10 16 3 3
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owtler/FdLilily Name Pellner Inc
Facility Contact
Street Address
City
County
Telephone No.
4016 Shutterfly Road
Charlotte
Mecklenburg
704 605-5989
State NC
E-mail Address
Fax:
ZIP Code 28217
[e-mail]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
0 Facility closed or is closing on 12/9/18 . 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 and cILLUIale.
Signature
Edward Everhart
Print or type name of person signing above
Please return this completed rescission request form to:
Date 8-March-2019
Quality, Customer Service, and Environmental Manager
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018]an10