NCG140467_Rescission Request_20191114

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Division of Energy,'Nlineral & 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
REC-T INIF 0
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. NOV 1
DENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I N I C I G 1 1A046 71 0'*b
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.
The Lane Construction Corporation
Christopher M. Ange
4860 Lawndale Drive
Greensboro
Guilford
336 406-9060
State NC ZIP Code 27455
E-mail Address [e-mail]
Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on 1 1 /8/19. 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
Thomas C. Meador Digitally signed by Thomas C. Meador
Date: 2019.11.08 12:25:17-05'00'
Thomas C. Meador
Print or type name of person signing above
Please return this completed rescission request form to:
Date
Project Director
Title
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]
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