NCG080962_Rescission Request_20190523

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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
PFIr77IN 1!_1r)
MAY 23
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permitDENR-LAND 0LIAL!7'(
STORMWKI'Ek IaEkivii I i ING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S N I C I G 10 18 10 19 6 2
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Amazon.com Services, Inc
Facility Contact
Street Address
City
County
Telephone No.
NA Environmental Department (ATTN: Eric Chapman)
PO Box 80842
Seattle
King
206 413-4526
State WA
E-mail Address
Fax: NA
ZIP Code 98108
[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: Request to transfer coverage from Permit NCG080000 to Permit NCG060000 for Amazon.com Services, Inc - CLT2 located
at 10240 Old Dowd Road, Charlotte, Mecklenburg County, NC 28214. NOI for coverage under Permit NCG060000 is attached.
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
sucl I info) mation is true, complete and accurate.
Signature " � V.L" Date 5/15/2019
Kevin Winston Global Field Environmental Lead
Print or type name of person signing above
Please return this completed rescission request form to
Revised 20183an10
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612