NCG070009_Rescission Request_20191031

Division of Energy, Mineral & Land Resources
'•'' Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
Quality 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
N I c I s 10 17 10 10 10 10 1 1 N I c I GO 17 10 10 10 19
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Na
Facility Contact
Street Address
City
County
Telephone No.
Adams Products
Doug Shelton
1062 2nd Avenue NW
Hickory
Catawba
828 322-6221
State NC ZIP Code 28601
E-mail Address doug.shelton@ c m nn
Fax: -_ _0 -- U
OCT 3 12019
3) Reason for rescission request (This is rectuired information. Attach separate sheet if ni sS81Ab QUALITY
❑ Facility closed or is closing on All industrial activities have ceased such thatQno�dischiarg�e�s �I TC T!NG
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:
This facility is only used for sales of masonry block, concrete pavers and building materials
All industrial activities and manufacturing processes have ceased such that no discharges of stormwater are contaminated by exposure to industrial activities or materials
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
Doug Shelton
Print or type name of person signing above
Date 10-28-19
EH&S Manager
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 2018Jan10