HomeMy WebLinkAboutNCG140020_MONITORING INFO_20180801STURMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV Cc u
DOC TYPE
❑HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ �ol q o� � I
YYYYMMDD
Environmental
Quality
Division of Energy, iMineral & Land Resources
Land Quality Section/Stormwater Permitting Prograrn
National Pollutant Dischas-ge 1-- imination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Rr C
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit. SEP 1. 7 2018
1) Enter the permit number to which this request applies: CENTRAL FILES
Individual Permit (or) Certificate of Coverage DwR SECTION
N I C s N I c I G 1 1 4 10 10 2 0
Z) owner/Facility Information: "Final correspondence will be mailed to the address noted below
Owner/Facility Name S&W Ready Mix Concrete Company LLC - Warsaw Plant
Facility Contact
Street Address
City
County
Telephone No.
i
+r
Hank Gay
344 NC Hwy 50-117
Warsaw State NC ZIP Code 28398
Duplin E-mail Address hgay@snwreadymix.com
910 284-2664 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑r Facility closed or is closing on 1 /1 /2003. 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:
1, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
subject facility. 1 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 F )' f '- Date 7126118
Hank Gay Environmental Coordinator
Print or type name of person signing above Title
Please return this completed rescission request form to
Revised 20183an10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27694-1612
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4/3 0 2011
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