NCG140253_Rescission Request_20210310

Division of Energy, Mineral & Land Resources
C--
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Fnvironmental
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year Month
Day
11
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 I 5 N I C I G 11 14 10 12 15 13
2) Owner/Facility information: * Final correspondence will be mailed to the address noted below
Owner/Facility NameSouthern Equipment Company Inc, Ready Mix Concrete Company - Wilmington Plant #63
Facility Contact
Street Address
City
County
Telephone No.
Steve Simonsen
5125 Hwy 421
wnmington State NC ZIP Code 28401
New Hanover E- 1 Add ssimonsen@ar os u
770 356-7285
mal ress g - us
Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
Facility closed or Is closing an . All industrial activities have ceased such that no discharges of
stormwater are conta minateG by exposure to industrial achvuh.9 or materials.
Q✓ Facility acid to Coastal Precast n 2018 If the facilitywill continue new o operations under the n caner 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 tr , complete and accurate.
WSignature ` Date 4/)/,w I
7 � /p �� �j`id.USfN f films. MS d
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 201&lan10