NCG140177_Rescission Request_20210323

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Date Received:
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
Rescission Request Form
Please fill out and return this farm if you no longer need to maintain your NPDES stormwo ter permit.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program, 1612 Mail Service Center, Raleigh, NC 27699-1612. The submission of this form does not
guarantee exclusion from NPDES stormwater permitting. Prior to exclusion from NPDES stormwater permitting a
site inspection will be conducted.
1. Owner/ODerator (to whom all Dermit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
Carl Rose and Sons ready -mix concrete
Isaac Rose
Street address:
City:
State and zip code:
605 winston rd
jonesville
ncTelephone
number:
Email address:
336-469-7542
[e-mail]
2. Industrial Facility {facility reciuesting rescission):
Facility name:
Carl Rose and Sons ready -mix concrete
Street address:
605 winston rd
City: State:
Zip Code:
T28642
I
County:
ladkin
Jonesville NC
Permit Number to which this request applies:
ncg140177
3. Reason for rescission Request
This is required intormation. Attach separate sheets it necessary.
0 Facility is closed or closing. All industrial activities have ceased such that no discharges of stormwater are contaminated
by exposure to industrial activities or materials.
Date closed/closing-
• Facility sold.
Sold to: Mathis Concrete
On date: 2/15/2019
0Other (please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.6E (1) provides that: Any person who knowingly makes any false statement,
representation, or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may Include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
El I, as an authorized representative, hereby request recission 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.
Printed Name of Person Signing: Isaac Rose
Title: Safety Officer
(Signature of Applicant)
3/23/2021
(Date Signed)
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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