NCG050310_Rescission Request_20190405

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
APR 0 5 2019
Please fill out and return this form if you no longer need to maintain our NPDES stormwater DENR-LAND Ql1ALITr
Y 9 Y p"NNIvVATER PERMI f )7NG
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C I s N I c I G 10 5 0 3 1 0
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Narne boiioco Pioducty CouiNrany - I ortyL City I'lard
Facility Contact
Street Address
City
County
Telephone No.
Paul B. Douglas, (tri)704-929-7458, (o) 828-328-2466 ext. 2265
681 Piney Ridge Road
Forest City
Rutherford County
828 328-2466 ext 2265
State NC
E-mail Address
Fax: 828
ZIP Code 28043
[e-mail]
328-8369
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:
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
suc.l r If Irui I rlaLlul I Is Li ue, c of nplete d1 id ac,c,ul crEe.
Signature Date April 1, 2019
Paul B. Douglas Quality Assurance & Environmental Manager
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 2018Jan10
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612