NCS000521_Rescission Request_20190322

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System ° !•-
Environmental !`{AR 22 2019
Quulity RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES stormwa&r5
TER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I 5 O 1 o 1 O 19 1 2- I N I C I G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below_,
Owner/Facility Name
r-
Facility Contact ,iL E ES 77/4- 4--
StreetAddress220
City P,(7—rr nr'L. 0 State N C- ZIP Code 2 71�/ 2
County L-%e?- 79� &M E-mail Address LyL6- , Esj'YL� 141 L , CpM
Telephone No. ! q 2 0 0 -,S'Sy q Fax: /Vo/VC
C
/U
3) Reason for rescisslun reyuesl (ThIs Is reyulred liifuiiridl.luii. All.dLI1 Sepdidle sheet if HeLessdiy):
❑ 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.
j Other: CD�UELMI) 7-6 A- It it
7)ISM/cl- Il S>=Z�fNG-- ��Z�M L
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 9hype name of person signing above
Please return this completed rescission request form to
Date 0, ) 1 -7
M 4M �E
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleiqh, North Carolina 27699-1612
Revised 2018Jan10