NCG160018_Rescission Request_20191120

Kro
Environmental
Quality
Division of Energy, :Mineral R Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year i Month Day
NOV 20 2019
Please fill out and return this form if you no longer need to maintain your NPDES stormwaterLoi�iL.AND QUALITY
;,TORMWATER PERPiiITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C � 1 .6 0 10 1 18
2) Owner/Facility Information: ' Final correspondence will be mailed to the address noted below
Owner/Facility Name Carolina Paving of Hickory,lnc. Carolina Aspnalt
Facility Contact Jim Taylor
Street Address 445 9th St SE
City Hickory State NC ZIP Code 28602
County Catawba E-mail Address [e-mail]
Telephone No. 828 3124898 Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
21 Facility closed or is closing on 8/2014 . 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 11/14/2019
m Taylor Estimator
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 20183an10
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612