NCG170098_Rescission Request_20190603

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
`r, F='N
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permi y2019
DENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N I C I S N I C I G 11 17 10 10 19 8
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Valdese warehouse LLc
Facility Contact
Street Address
City
County
Telephone No.
Bruce O. Stacy
3262 Greentree Acres
Valdese
Burke
828 439-5624
State NC ZIP Code 28690
E-mail Address
Fax:
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 was sold several years ago. No longer have documentation of sale.
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
such information is true, complete and accurate.
7 .
Signature Date
Bruce O. Stacy
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 2018Jan10