NCGNE1013_Rescission Request Form_20190509

FOR AGENCY US✓- ONLY
KC
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
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
N I C I 5 I I I I I I I I N I C I G. I N JE 11 0 1 13
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name WestRock
Facility Contact
Rob Bockstmck
Street Address
2750 Whitehall Park Drive
City
Charlotte
County
Mecklenburg
Telephone No.
314 656-5367
State Nc ZIP Code 28273
E-mail Address [e-mail]
Fax: Nra
3) Reason for rescission request (This is MuirMuiro information. Attach separate sheet if necessary):
❑f 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:
1, as an authorized representative
subject facility. 1 arry=a liar with
such information is'tru'&corflolete
Signature
Robert F Bockstruck
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 2018Jan10
of coverage under the NPDES Stormwater Permit for the
in this request and to the best of my knowledge and belief
Date 08 M A, r Z
Environmental Service Manager
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612