NCG020484_Rescission Request_20200909

FOR AGENCY USE ONLY
Division of Energy,Mineral& Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System P E C E I`/F D
Environmental
Quality RESCISSION REQUEST FORM EP 0 9 2020
[ENR-LAND QUALITY
Please fill out and return this form if you no longer need to maintain your NPDES stormwa elr( aIR PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C S N C G 0 2 0 4 8 4
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name Cross Road Sand Pit(Davenport Incorporated)
Facility Contact David Keith Davenport
Street Address PO Box 164
City Plymouth State NC ZIP Code 27962
County Washington E-mail Address [e-mail]
Telephone No. 252 793-4978 Fax:
3) Reason for rescission request(This is(required information. Attach separate sheet if necessary):
0 Facility closed or is closing on 2020 . 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 Q Date September 1, 2020
David Keith Davenport Owner/operator
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 20183an10