NCG140180_Rescission Request_20231026

DEMLR USE ONLY
Date Received BIMS Rescission Date Permit Number
RECEIVE
NC DEQ Division of Energy, Mineral and Land Resources Y
?ZZP
STATE STORMWATER: SEP — S
PERMIT RESCISSION REQUEST FORM
DEMLR
ONLY for when the permittee of record wishes to rescind an existing State Stormwater q rp���I�Pal Office
one of the options below. The permittee must complete, sign and submit this original forrrl 87t fooirl
DEMLR Regional Office, which can be determined by locating the project on the interactive online map at:
http://deg.nc.gov/contact/regional-offices.
1. State Stormwater Permit Number: NCG140180
2. Project name: Concrete Service Company, Inc. - Plant 16 - 393 Rankin S� t. Fayetteville, NC
3. ® 1 am the current permittee of the permit to be rescinded. (If you are not the current permittee, either the
current permittee must complete this form or you must apply to transfer the permit and receive
approval before you can apply to rescind the permit).
4. Rescission options (select only one response below)
❑ a. This project has been or will be replaced by a separate permit issued by the Division.
❑ If the new permit number has been assigned: SW
❑ If a new permit number has not been assigned, the proposed facility name:
® b. This project has not been constructed and there are no future plans to do so under this approval. 1
understand that any vested rights or prior authorizations are forfeited based on this request.
❑ c. This project has received approval from the City of Wilmington under their post-construction ordinance
which includes and covers both the previously approved construction under the State permit, and all
subsequent new construction.A copy of the new permit issued by the City of Wilmington must be
submitted along with this form.
❑ The permit/approval number issued by the City of Wilmington:
❑ I acknowledge and understand that this delegated local government may impose stricter design
requirements for the existing part of the project.
❑ I acknowledge that this delegated local government may assess annual fees for its stormwater
permits. For comparison,the State charges$505.00 to transfer a permit or to modify a permit, and
$505.00 every 8 years to renew a high-density permit.
Signature requirements for the named signing official representing the current permit holder must meet the
requirements listed in NCAC 02H.1040(1).
I, Bob Allen, Jr. the current permittee, am submitting this request to
rescind the above-listed stormwater permit. I attest that this request for a permit rescission is made with the full
knowledge and understanding of the above-listed facts. I understand that the subject state stormwater permit will not
be rescinded until a copy of the permit issued by the delegated local government is submitted to DEMLR, or the
replacement permit is issued, or it is confirmed that the project has not been constructed.
Signature: Date:
I, /1 �/J hl �• �� nl'Z a Notary Public for the State of
r t�Y4 I 0—f D LC/ County of u M 6 er�4 /t G� do hereby certify that
/✓d b ��`� _V � ,n personally appeared before me this the
day of �`f""r'�"`�t 20 23 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal, ����y'lbtgry, eal
NN1 EAt� )
No
Notary Signat
A�18C
My commission pires j I 2 `� 12-47 C j Z
Stormwater Permit Rescission Request Form Page 1 of 1 rlrrrre/tt ?G,`� March 14, 2019