NCG030648_Rescission Request_20190715

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elunination System
Envi3-Gn xF: ntal
il"'C'11-Y RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
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 Permit (or) Certificate of Coverage
N I c I S N _0 f_3 10 I Q 10 10
I I WL
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Na
Facility Contact
Street Address
City
County
Telephone No.
Schletter Inc.
Janice Wiebelhaus
1001 Commerce Center Drive
Shelby
Cleveland
704 595-4049
State NC ZIP Code 28150
E-mail Address [e-mail]
Fax: [phone]
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: No longer teasing the building. New occupants take possession 711/2019.
4) Certification:
I, as an authorized represent,
subject facility. I am familiar
such infar�ma�i'on is true. corn
Wiebelhaus
: or type r
eby request rescission of coverage under the NPDES Stormwater Permit for the
information contained in this request and to the best of my knowledge and belief
accurate.
of person signing above
Please return this completed rescission request form to:
Revised 20183an10
Date
Assistant Controller
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612