NCG140444_Rescission Request_20200428

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
RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
DENR-LAND QUALITY
1) Enter the permit number to which this request applies: STORMWATER PERMITTING
Individual Permit (or) Certificate of Coverage
N I C S N I C G 1 1 4 1 0 4 4 4
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility NameMCCARTHY IMPROVEMENT COMPANY
Facility Contact
Street Address
City
County
Telephone No.
JACKIE NELSON
5401 VICTORIA AVE
DAVENPORT
SCOTT
563 344-3726
State IA
E-mail Address
Fax: 563
ZIP Code 52807
J N ELSON@MCCARTHYI M PROVE I
344-3720
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on . 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.
r Q
Signature Date
J'
M 11k- Darll!t�
Print or type name of person signing above 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 20181an10