NCG160101_COMPLETE FILE - HISTORICAL_20090216

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- - STORMWATER-DIVISION CODING SHEET -
RESCISSIONS.
PERMIT NO.
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DOC TYPE
COMPLETE FILE - HISTORICAL
DATE OF
RESCISSION
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Permit Rescission Request Form
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National Pollutant Discharge Elimination System
General Permit NCG160000
Certificate of Coverage Number
NCG160101
Please fill out and return this form only if you no longer need to maintain your NPDES stormwater permit.
The following is the information currently in our database for your facility. Please review this information carefully and
make all corrections as necessary in the space provided to the right of the current information.
Owner Affiliation Information *Rescission Correspondence wi//be mailed to the owner address
Owner / Organization Name:
Owner Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
Rose Brothers Paving Co Inc
Eugene Rose
PO Box 806
Ahoskie, NC 27910
252-209-8144 Ext.
252-209-8148.
[e-mail]
Facility/Permit Contact Information
Facility Name: Rose Brothers Paving -Gas
Facility Physical Address: Sr 1200
Facility Contact:
Mailing Address:
Phone Number:
Fax Number:
E-mail address:
Gaston, NC 27832
W Reid Clarke
PO Box 806
Ahoskie,NC 27910
252-209-8144 Ext.
252-209-8148
Reason for rescission request (This is reouired information. Attach separate sheet if necessary):
REQUEST AND CERTIFICATION
I, as an authorized representative, hereby request rescission of certificate of coverage NCG160101 under NPDES
Stormwater General Permit NCG160000 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
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Print or We name of person signing above
Date Z 13-og
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Title
Please return this completed rescission request form to: SW General Permit Coverage Rescission
Stormwater Permitting Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617