NCG170401_Rescission Request_20190806

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
REOFIVED
stj
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 PIPE
N I C I 5 N I C I G 11 7 0 0 S cd *
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Duvaltex (US), Inc
Facility Contact Scott Taylor
Street Address 304 E Main Street
City Elkin State NC ZIP Code 28621
County Surry E-mail Address [e-mail]
Telephone No. 207 876-1418 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑� Facility closed or is closing on 8/1 1/19 . 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
Scott Taylor
Print or type name of person signing above
Please return this completed rescission request form to
Date Z 1— l 9
Environmental Coordinator
Title
DEMLR - Stormwater Program
Dept. of Environmental Quallty
1612 Mail 5eivice Center
Raleigh, North Carolina 27699-1612
Revised 20181an10