NCG140449_Rescission Request Form_20200504

NCDENR
NORTH CAROLINA DEPARTMENT OE
EWIRONMENT AND NATURAL RESOURCES
Division of Energy, Mineral & 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
RECEIVED
Please fill out and return this form if you no longer need to maintain your NPDES stormwateO XX A 2070
1) Enter the permit number to which this request applies: DENR-LAND OVAUTY
STORWMTERII ERMITTHv(--'.
Individual Permit (or) Certificate of Coverage
N I C I S N C I G 11 40 A 4T9
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name The Lane Construction Corporation
Facility Contact Casey P Hurley
Street Address 306 East NC Highway 152
City China Grove State NC ZIP Code 28023
County Rowan E-mail Address [e-mail]
Telephone No. 919 279-7264 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on 4/1/20 . 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 4.24.2020
C sey P H rley Project Manager
Print or type name of person signing above Title
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, North Carolina 27699-1612
Phone: [phone] FAX: [phone]
An Equal Opportunity 1 Affirmative Action Employer