NCG140191_COMPLETE FILE - HISTORICAL_20160607

STORMWATER-DIVISION CODING SHEET -
RESCISSIONS .
PERMIT NO..
DOC TYPE
❑ COMPLETE FILE - HISTORICAL
DATE OF
RESCISSION
❑ .
YYYYMMDD

LPWA
6t NC®EN
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Division of Energy, Mineral & Land Resources
Land Quality Section/Storm water Permitting Program
National Pollutant Dischnr,,e Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
l Month
I Day
RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES.stormwater permit.a
ST,Rc,Y l r, 1D QUALITY
1) Enter the permit number to which this request applies: ATER PERNIlTTIi,1C
Individual Permit (or) Certificate of Coverage
2) Owner/Facility Information: • Final correspondence will be moiled to the address noted below
Owner/Facility Name CEMEX Construction Materials Atlantic LLC
Facility Contact Denise Corrales Director Environmental - Materials Division
Street Address 3820 Northdale Blvd., Suite 100E
City Tampa State FL ZIP Code 33624
County Hillsborough E-mail Address [e-mail]
'Telephone No. 813 269-103S Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on F-712 . All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to t""':-; -1 on =1 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 /�
Denise Corrales
Date 6/7/2016
Director Environmental
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center. Raleigh, Muth Carolina 27699-1612
Phone: 919-90i 63001 FAX: [phone]
An Equal Opportunity 1 Afflrmalive Action Employer