NCG140444_Rescission Request_20171012

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
?. Land Quality Section/Stormwater Permitting Program Year Month Da
National Pollutant Discharge Elimination System
Energy, Mineral RESCISSION REQUEST FORM
and Land Resources
ENVIRONMENTAL QUALITY
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 I I I I I I J I N I C I G 1 1 4 1 0 1 4 4 4
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name: McCarthy Improvement Company/ McCarthy Henderson Concrete Batch Plant
Facility Contact
Street Address
City
County
Telephone No.
Kevin Crusa
3950 US 1
Henderson State NC ZIP Code 27537 _
Vance E-mail Address [e-mail]
[phone] Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on 8/26/2017 . 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
Date /D —S -a O 17
Kevin CruSa Proiprt Manager
Print or type name of person signing above Title
Please return this completed rescission request form to:
NPDES Permit Coverage Rescission
RECEIVE
Stormwater Permitting Program
1612 Mail Service Center
OCT 12 2017
Raleigh, North Carolina 27699-1612
DENR=LAND WALITY
()RMWATER PEW01771r4e