NCG140177_Rtn lnv Ltr_20200725

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
BRIAN WRENN
Director
Dexter Lee Rose
PO Box 38
Jonesville NC 28642
NORTH CAROLINA
Environmental Quality
July 21, 2020
Subject: Rescission Request
NCG140177
Carl Rose and Sons - Hivy 67 Ready Mix
Yadkin County
On July 20, 2020 the Division of Energy, Mineral & Land Quality received your note
indicating the above facility has been closed for business since March 20, 2019.
Please complete the enclosed Rescission Request form and return it to:
Stormwater Program
Attention: Suzanne McCoy
1612 Mail Service Center
Raleigh NC 27699-1612
Thank you for your attention to this matter. If you have any questions, please
contact me at [phone].
Sincerely,
ve C—�
Suzanne McCoy
Stormwater Program
Administrative Assistant
I XIE 274 FE 1 0007/25/20
RETURN TO SENDER.
NOT DELIVERABLE AS AYDDRESSED
UNABLE TO FORWARD
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North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh, North Carolina 27699-1612
919.707.9200

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year VE®
National Pollutant Discharge Elimination System 2 V p 2020
RESCISSION REQUEST FORM DENR-LAND QUALITY
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
N I C S' N C G
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name
Facility Contact
Street Address
City State ZIP Code
County E-mail Address
Telephone No. 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
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
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 2018Jan10
Date
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612

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