NCG050360_Rescission Request_20190708

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
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National Pollutant Discharge Elimination System
EnWronmental
Quolit), RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Jut ()8 2JJ
Please fill out and return this form if you no longer need to maintain your NPDES stormwater
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Individual Permit (or) Certificate of Coverage
N I C I s os o 316 0 I I N I C I G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name G-e_Vle.ra j cs (_a►^A
Facility Contact
Street Address
City
County
Telephone No.
State
4 E-mail Address
7�2-f - 30_521 Fax: 757
ZIP Code 3LfS1')
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3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
X 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 d c rmL Wo , J L LC� 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 information is true, complete and accurate.
Signature
Print or type name6f person signing above
Please return this completed rescission request form to:
Date 71� �
C on, r
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10