NCS000046_Rescission Request Form_20220315

FOR AGENCY USE ONLY
Assigned to:
ARO FRO
MRO RRO WARO WIRO WSRO
Division of Energy, Mineral, and Land Resources Land Quality IIp� t gn ��Ch
National Pollutant Discharge Elimination System 1� Cu
Rescission Request Form MAR 1.5 2022
DEN UND QUALITY
Please fill out and return this form if you no longer need to maintain your NPDES stormwa&TgAMTERP TTIW
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program, 1612 Mail Service Center, Raleigh, NC 27699-1612. The submission of this form does not
guarantee recission of your NPDES stormwater permit. Prior to the recission of your NPDES stormwater permit, a
site inspection will be conducted.
1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Airgas USA LLC
Legally responsible person as signed in Item (4) below:
Jeremy Kenworthy
Street address:
City:
State and zip code:
630 United Drive
Durham
27713
Telephone number:
Email address: w
919-272-6683
[e-mail] `
2. Industrial Facility (facility requesting rescission):
Facility name:
ASG Durham
Street address:
630 United Drive
City:
State:
Zip Code:
County:
Durham
NC
27713
Durham
Permit Number to which this request applies:
NCS000046
3. Reason for rescission Request
I nis is requires mrormavon. Hiiacn separate sneeis IT necessary.
0 Facility is closed or c[asi g. All industrial activities have ceased such that no discharges of stormwater are contaminated
by exposure to industrial activities or materials.
Date closed/closing:
E3 Facility sold.
Sold to:
On date:
OOther (please explain):
Original SIC code 2813 used In delerminalion and applica6un is Incorrect. The correct SIC for the Durham NC operation is 5169 which does not require a stormwaterpermit.

4. Applicant Certification:
North Carolina General Statute 143-215.613 (i) provides that: Any person who knowingly makes any false statement,
representation, or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
l I, as an authorized representative, hereby request recission 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.
Printed Name of Person Signing: Jeremy Kenworthy
Title: Airgas Plant Manager
`/
(Signatux of Applicant)
2/23/2022
(Date Signed)
Mail the entire package to: DEMLR —Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC27699-1612
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