NCS000373_Rescission Request_20191001

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
N Z_ National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
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 S0 10 10 13 17 13 1 N I C I G
'� .>a !$F:D
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below OCT U 2019
Owner/Facility Name Michelin Aircraft Tire Company, A division of Michelin North America, Inc.
LITY
Facility Contact Chris Crisler STORMWATER PERMITTING
Street Address 40589 S. Stanly School Rd.
City Norwood State N.C.
County Stanly County E-mail Address
Telephone No. 704 474-7777 Fax:
ZIP Code 28128
[e-mail]
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.
❑✓ Other: Facility is requesting coverage under general permit NCG050000 r'1C & DSD ` L4(0 Q ✓ o <<Lt L1�1
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 complete and accurate.
Signature O;J�Date
Shannon Bernhardt
Print or type name of person signing above
Please return this completed rescission request form to
Revised 2018Jan10
Plant Manager
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612