NCG020314_Rescission Request_20201112

Division of Energy,Mineral& Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section/Stormwater Permitting Program Year Month Day
' National Pollutant Discharge Elimination System RECEIVED
Environmental
Quality RESCISSION REQUEST FORM NOV 12 2020
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permitl.)ENR LAND QUALITY
I ORMWATER PERMITTING
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N C S N C 6 0 2 0 3 1 4
2) Owner/Facility Information: *Final correspondence will be mailed to the address noted below
Owner/Facility Name Fort Bragg Lamont West Borrow Pit
Facility Contact Monica Stephenson
Street Address DIRECTORATE OF PUBLIC WORKS IMBG-PW 2175 REILLY ROAD STOP A
City Fort Bragg State NC ZIP Code 28310-5000
County E-mail Address [e-mail]
Telephone No. 910 396-4900 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: The Lamont West Borrow Pit has no direct discharge to surface waters.The nearest surface water is a mile away.
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 "°AA/ UAti v o Date 12M` Lt)
Monica Stephenson Director of Public Works
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 2018Jan10