NCG020959_Rescission Request_20210721

FOR AGENCY USE ONLY
F • wW Division of Energy, Mineral & Land Resources Date Received
Year Month Day
Land Quality Section/Stormwater Permitting Program
NCDENR
National Pollutant Discharge Elimination System
NORTH NVICPROLINA DEPARTMENT OF 1 (� L wo��
ERONMENT AND NMAL URRESOURCES
RESCISSION REQUEST FORM L {ir
rr
Please fill out and return this form if you no longer need to maintain your NPDES stormwatet0ATER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
Iv C s I I N I c I G 10121 0 1 9 15 19
2) Owner/Facility Information: * final correspondence will be mailed to the address noted below
Owner/Facility Name HOM Development, LLC / Wilbur Griggs Mine
Facility Contact Jamie B. Hatchell
Street Address PO Box 2405, 1002 Driftwood Drive
City Manteo State NC ZIP Code 27954
County Currituck E-mail Address jam ie(_d_)hatchellconcrete.com
Telephone No. 252-202-1501 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
EXI Facility closed or is closing on 7-1-21 . 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 acme, %itally signed by Ken Elliott
Ken El l i o ttlli
e CN=Ken Elliotta acc racytt and into.
E=kenakenobx.com
Reason. I attest to the accuracy and integrity of this
document
Signature Loca ton Elliott Consulting Date July 7, 2021
Date
Kenneth Elliott
Print or type name of person signing above
Please return this completed rescission request form to:
Authorized representative for
Title HOM Development, LLC
NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer

WIF
• Division of Energy, Mineral & Land Resources
�'�
Land Quality Section/Stormwater Permitting
��1 AA Q y ttrng Program
RCDENRNational Pollutant Discharge Elimination System
Norms CA iO� Derrxrworr or
ENVIRONMENT nno Nmuft . Resounecs
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
lu I c I s I I I I N I C I G 1 0 2 10 1912 131
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name HOM Development, LLC / Bayview Sand Mine
Facility Contact Jamie B. Hatchell
Street Address PO Box 2405 / 1002 Driftwood Drive
City Manteo State NC ZIP Code 27954
County Currituck E-mail Address iamieC�hatchellconcrete.com
Telephone No. 252-202-1501 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑x Facility closed or is closing on 7-1-21 . 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 "" 15at%signed by Ken Elliott
DN: CN=Ken Elliott, O=Elliott Consulting,
Ken Elliott Reason t kenobx corn
Reason: I attest to the accuracy and integrity of this
document
Signature Location. Elliott Consulting Date 2 - Date July 7, 2021
Kenneth Elliott Authorized representative for
Print or type name of person signing above Title HOM Development, LLC
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer