NCS000045_Rescission Request_20190919

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year I Monm Day
ho. National Pollutant Discharge Elimination System
Iroom or
Q;4uhty RESCISSION REQUEST FORM
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S O 0 10 10 4 5 N I C I G
Zj Owner/Facility Information: • Final correspondence will be mailed to the address noted below
Owner/Facility Name Airgas, USA LLC
Facility Contact
Street Address
City
County
Telephone No.
Jerrell Cook
5313 Old Dowd Rd
Charlotte State NC ZIP Code 28208
Mecklenburg E-mail Address [e-mail]
704 644-3317 Fax:
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 reissue to permit to the new owner.
Q Other: Activity which resulted in our facilties to be identified as sic code 2183 have ceased.
We request a rescission of the individual permit and it's requirements.
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 i�ue, complete and accurate.
Signature
6-
Ae rretl 6_ coakf
or type name of person signing above
Please return this completed rescission request form to:
Revised 20183an10
Date qXO4 0
s&_'oJe- &C,7
Titl
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612