NCG020423_Rescission Request_20230608

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FOR AGENCY USE ONLY N*oZo %HIVE®
Assigned to: C CrC9k 10
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ARO FRO MRO RRO WAR WI WSRO DE,.—. A--OtormwaterProgram
Division of Energy, Mineral, and Land Resources land Quality Section
National Pollutant Discharge Elimination System
Rescission Request Form
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
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 organizatioWl entity: Legally responsible pgrson as signed in Item(4)below:
N OL, 1. J�QI�L / ,euat0 L Jo/3pL
Street add ity(lM/kG�ON S e and zip code:
1fl a o C' i Vt7 V N b
T phone num -- Email ad
2. Industrial Facility(faci ' esting re
FadlR name:
Street ad
Gill,)
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, State:
Permit Num c whi is request applies
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3. Reason for rescission Request
This is required information.Attach separate sheets if necessary.
Facility is dosed or closing.All industrial activities have ceased such that no discharges of stormwater are contaminated "
exposure to industrial activities or materials. �1
Date closed/dosing: 'TA� I 102.V
13 Facility sold.
Sold to:
On date:
13 Other(please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.6B(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 pass 2 misdemeanor which may include a fine not
to exceed ten thousand dollars($10,000).1 hereby request exclusion from NPDES stonnwater permitting.
Under penalty of law,I certify that:
fl 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: AQAi a Q L . SoRD
Title: OW N EIZ
W6 j2oa3
(Signature ofApplirant) (Date Signed)
Mail the entire package to: DEMLR—Stormwater Program
Dep
la eighai er
s
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