NCG050148_Rescission Request_20190515

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month oay
` Envr`rorrmeni'al National Pollutant Discharge Elimination System
Qualify RESCISSION REQUEST FORM P F017W O
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: STORDENR1�11NATER ATER-LAND QUALITY
PERMITTING
Individual Permit (or) Certificate of Coverage
N C S
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Edwards Brothers Malloy
Facility Contact Robie Mills
Street Address 900 Edwards Brothers DR
City Lillington State NC
County Harnett ZIP Code 27546
Telephone No. 910 263-1355 E-mail Address [e-mail]
Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
0 Facility closed or is closing on 6/15/18 . 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 NPDCS Storrriwater 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
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 2018Jan10
Date/ A'�f�?
!{J
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612