NCG080312_Rescission Request_20190904

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Division of Energy, Mineral & Land Resources
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Land Quality Section/Stormwater Permitting Program
...... National Pollutant Discharge Elimination System
f =`` RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
RFC,FIf �
Please fill out and return this form if you no longer need to maintain your NPDES stormwate , IND QUAI IT<
STORIVIVIATER PERM1171NG
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 N I C 1 G 1 Cl I q I a
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
OwnerjFaciiity Name ti r3 n rr 6 "met re _r "0 4LP-0
Facility Contact
Street Address
L
City ,'n rs G k es v t lCF'
County
Telephone No.
W
State f1V'_C' ,ZIP Code
E-mail Address
Fax:
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.
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 name of person signirfg above
Please return this completed rescission request form to:
Date ,r� '0 - .� 1
(�) lil rim . ✓
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 20181an10