NCG050442_Rescission Request_20181127

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Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
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€ uality RESCISSION RE UES
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
RECEIVED
Q T FORM NOV 2 i
Please fill out and return this form if you no longer need to maintain your NPDES stormwjer AND QUAL1Ty
Rfv1WgTER l'�RMITT1rUG
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I 5 1 (0C1C ' TJ t+ N I C I G 5 q c( a
2) Owner/Facility Information-' * Final rarrespandence will he mailed to the address noted below
Owner/Facility Name L_ LLC_
Facility Contact
Street Address
City
County
Telephone No.
GV•P.- V..,-r L----) -f- u�
t o c 0 ►mot. cs i r Sk�,s-k-
313 l
State IN I'-- ZIP Code '1073 ST
E-mail Address
Fax: `i 1 40 `1I'l _ 3 2 Lt�
3) Reason for rescission request ( I his 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.
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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 coi ildii ied in this request and to the best of my knowledge and belief
such information is true, complete and accurate.
Signature .L ...� Date 0 8 /9
CJG�G�GIc CJ,CEN1�/�c/ AAA1 r WAV4CfX-
Print or type name of person signing above Title
Please return this completed rescission request form to:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10