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HomeMy WebLinkAboutNCG070009_Rescission Request_20191031Division 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 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 10 17 10 10 10 10 1 1 N I c I GO 17 10 10 10 19 2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below Owner/Facility Na Facility Contact Street Address City County Telephone No. Adams Products Doug Shelton 1062 2nd Avenue NW Hickory Catawba 828 322-6221 State NC ZIP Code 28601 E-mail Address doug.shelton@ c m nn Fax: -_ _0 -- U OCT 3 12019 3) Reason for rescission request (This is rectuired information. Attach separate sheet if ni sS81Ab QUALITY ❑ Facility closed or is closing on All industrial activities have ceased such thatQno�dischiarg�e�s �I TC T!NG 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: This facility is only used for sales of masonry block, concrete pavers and building materials All industrial activities and manufacturing processes have ceased such that no discharges of stormwater are contaminated by exposure to industrial activities or materials 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 Doug Shelton Print or type name of person signing above Date 10-28-19 EH&S Manager 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