NCGNE0105_Rescission Request_20190628

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-- Division of Energy, Mineral & Land Resources
Laud Quality Section/Stormwater Permitting Program
National Pollutant Diseharge Elimination System
Environmental
Qu'aftty RESCISSION REQUEST FORM
FORAGi:NCY USS ONLY
Date Received
Year
Month
I Day
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:
Individual Perrmj it��j�T (or)
I C S I I P I
2) Owner/Facility Information: *Final correspondence will be
Owner/Facility Name
Facility Contact
Street Address
City
County
telephone No.
Certificate of Coverage
N C G h j .` ,? �J
to the address noted beta
JUN 28 2G13
3) Reason for rescission request (This is required information. Attach separate sheet if necessary
DENR-LA QUALITY
Facility closed or is closing on All industrial activities have ceased sucha`�i'�`��i�aF�g''b tf�^
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 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 informationistrue, complete and accurate.
Signature '—�� a� Date -2 5-�
ve
uwaak
Print or type name of person signing above Title t -^� t
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 20183anlo