NCG080963_Rescission Request_20190523

T
rw Division of Energy, Mineral & Land Resources
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
R F7('T77 °"
MAY 2 3 2013
Please fill out and return this form if you no longer need to maintain your NPDES stormwater peri ENR-LAND OVAL ITS(
STORMWATEK i✓ENIVii 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 8 10 9 6 3
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 NCGO80000 to Permit NCG060000 for Amazon.com Services, Inc - DLT1 located
at 3830 Parrott Drive, 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
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
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
Revised 2018Jan10