NCG030586_Rescission Request_20190806

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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
HEOFIVED
I , NID QUALITY
Please fill out and return this form if you no longer need to maintain your NPDES stormwater KaRki'tA/A.7E=t PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
M C S - N C G t) 3 Ci 5
2) Owner/Facility Infor 'nation: * Final correspondence will be mailed to the address noted below
Owner/Facilit
Y Name (L e c\ G.,6-'i (N�, �����-� � Y� C:
Facility Contact V ON6' t \S
Street Address
City
County
Telephone No.
StateC
t-) i15\u t_0 s E-mail Address
7 !I 1 S Fax:
ZIP Code
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
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 reissueto 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 Date i y
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