Loading...
HomeMy WebLinkAboutNCG160192_Rescission Request_20190211Division of Energy, Mineral & Land Resources j' Land Quality Section/Stormwater Permitting Program National Pollutant Discharge Elimination System Environmental Quality RESCISSION REQUEST FORM FOR AGENCY USE ONLY Date Received Year Month Da Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.:w'' T 1) Enter the permit number to which this request applies: �-' _�- C O7 2ui3 Individual Permit (or) Certificate of Coverage I nl QUAI W , N I C I S N C G 1 6 OT 11M % ERWl-F1'ING 2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below Owner/Facility Name Rogers Group Inc. - Burnsville Asphalt Facility Contact Street Address City County Telephone No. Van Medlock 421 Great Circle Road Nashville Davidson 615 780-5781 State TN E-mail Address Fax: 615 ZIP Code 37228 van.medlock@rogersgroupinc.com 564-5781 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 terminated lease with property owner (Trittico Investments, LLC) on December 31, 2017. 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 ►2(5�I$ rVan Medlock Director of Environmental Services Print or type name of person signing above Title Please return this completed rescission request form to: DEMLR - Stormwater Program Dept. of Environmental Quality 1612 Mail Service Center Raleigh, North Carolina 27699-1612 Revised 2018Jan10