NCG140482_Rescission Request_20210308

Environmental
Quality
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
[,IAR 08 2021
Please fill out and return this form if you no longer need to maintain your NPDES stormwater perwi."IR-LA!""D Dui_ ALI T 1`
1."IORkAWAXER PERi,Al1-1TING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N c sI I I I N I c I G 11 4 10 14 8 2
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name McCarthy Greensboro Elm Street Concrete Batch Plant
Facility Contact James Higgins
Street Address 1466 Sullivan Road
City Atlanta State GA ZIP Code 30337
County Fulton County E-mail Address [e-mail]
Telephone No. 563- 449-6779 Fax: NA
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 12/15/2(. 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 location is 1-73/North Elm Street Interchange, Greensboro, NC
Guilford County Facility closed as of 12/15/2020
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
C
James Higgins Project Engineer
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