NCG080935_Rescission Request_20190708

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
JUL 0 8 20
Please fill out and return this form if you no longer need to maintain your NPDES storn97 0Fh%A.LITY
STORMWATER PERMIT i"ING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I I I N I C I G 10 18 10 19 13 15
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility NameWalkertown Auto Ramp
Facility Contact
Street Address
City
County
Telephone No.
Will Hicks
3625 Williston Rd
Walkertown
Forsyth County
502 220-7125
State NC
E-mail Address
Fax:
ZIP Code 27051
[e-mail]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 06/30/19. 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:
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 ,ZL& Date 6. 26 , 19
Print or type name of person signing above Title
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 20183an10