NCG080765_Rescission Request_20200507

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
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
Iv I c I s I I I I I I N I 0 I 0 10 18 lo 7 6 5
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Na
Facility Contact
Street Address
City
County
Telephone No.
Florida Rock and Tank Lines, Inc.
M A:C I&C A)LA-LTY
1265 Cedar Hill Road
Leland
State NC ZIP Code 28451
CBrunswick E-mail Address �� c�� Sr����C��`j a cay)
t�o - Fax:
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 Quality Carriers, Irn on 4/25/,6. 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 ri 7 2-
Print or type name of person signi above Title
Please return this completed rescission request form to
Revised 2018Jan10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612