NCG210050_Rescission_20190930

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Emvie -on mentaI
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
RECEIVED
SEP 3 0 2019
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permiQENR-LAND QUALITY
STORMWATER PERMITTING
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 I N I C I G 2 1 0 0 5 0
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Atlantic Veneer
Facility Contact
Street Address
City
County
Telephone No.
Scott Vanderwerf
2457 Lennoxville Road
Beaufort
Carteret
252 723-9224
State NC
E-mail Address
Fax:
ZIP Code 28513
[e-mail]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 05/14/19 . 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. All log yard, sawmill, boiler, slicing, and drying operations have ceased.
The remaining operations of clipping and grading are contained under roof.
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 Date '~ i ' z �l °►
�ITz k&46 SL NSmca'"A I<Z ♦/S C.�,
Print or type name of person signing above Title
Please return this completed rescission request form to:
Revised 2018Jan10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612