NCG080971_Rescission Request_20190523

Division of Energy, Mineral & Land Resources
i' Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
MAY 2 3 2019
Please fill out and return this form if you no longer need to maintain your NPDES stormwater perR-LAND OUAI ITT
STORMWA TEF< Ncklvli 1 1 iNG
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C S N I C I G 10 18 0 19 7 1 1
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 - CLT3 located
at 6500 Davidson Highway, Concord, Cabarrus County, NC 28027. 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
such Information Is true, complete and accurate.
Signature
Kevin Winston
Print or type name of person signing above
Please return this completed rescission request form to
Revised 2018Jan10
Date 5/15/2019
Global Field Environmental Lead
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612