NCG030416_Rescission Request_20170508

�` • Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater ]Permitting Program
RCDENRNational Pollutant Discharge Elimination System
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RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Rwehred
Yaar
I Month
I Da
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) Certificate of Coverage
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G 36 /CA
2) Owner/Facility Information: • Anol correspondence wig be moRed to the address noted below
Owner/Facility Name Tar Pelt SACS k�r. , 1,cle_
Facility Contact %�r!/ M�2'e�r.++F/l z�i 5,
Street Address
City
County
Telephone No, 2 Z_
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State NC, ZIPCode 978oY
E-mail Address n
Fax: 2S2- 77 j'S7s`
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3) Reason for rescission request (This Is Muired Information. Attach separate sheet if necessary):
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CW Facility los 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 RJg11M_ on 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 StDrmwat er 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 accurate.
Signature Date 5-18
Print or type name of person signing above Title
Please return this completed rescission request form to:
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NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Cenler Ralelg5, North Carolina 27699-1612
Phone:91IM07-6300 FAX:[phone]
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