NCG130047_Rescission Form Dated 5-15-2019.pdf

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater ]Permitting Program
Ki�z_ National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
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 S I I I I I I N I C I G T 1 13 10 0 4 7
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Strategic Materials
Facility Contact
Street Address
City
County
Telephone No.
Dell Golanski
503 Junction Rd
Durham
Durham
281 923-2494
State NC
E-mail Address
Fax:
ZIP Code 27703
[e-mail]
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: Facility already has an NCG13 permit, Permit COC # NCG130019.
4) Certification:
I, as an authorized presentative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
subject facility. I fam' 'ar wit th of ation contained in this request and to the best of my knowledge and belief
such informatio ' r ccurate.
Signature Date 5-15-2019
Dell M Golanski SE Regional EHS Manager
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 20183an10