NCG020816_Rescission Request_20200820

1.,NI Division of Energy,Mineral& Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
Z
National Pollutant Discharge Elimination System FOR AGENCY USE ONLY
Environmental .FO F IVF D
Quality RESCISSION REQUEST FORM
AUG 20 2020
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
DENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N C S I N C G 0 z 0 ? I (p
2) Owner/Facility Information: A •Final correspondence will be mailed to the address noted below
Owner/Facility Name *&A t faL4 (,_LC. 03Or- k. fl)nc.
Facility Contact 4 rn t}c-hf--1-1-
Street Address 0. .B0x 12224
City t i rn i nq State �C ZIP Code 2 k405 J
County 7 f , l` �� E-mail Address f"11ie. den' y71-, - IC1 s.
Telephone No. q l0 200 544-'3, Fax: CQrr)
3) Reascua for rescission request(This is required information. Attach separate sheet if necessary):
Facility closed or is closing on 9-/S'/a.c� 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 l� �t??��
Date
l'1k , 1�1'1, Cht_LL t 1.2_3taGt.,4
Print or ty e name of person signing above /A m Title J
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 2018Jan10