NCG070033_Rescission Request_20210920

FOR AGENCY USE ONLY
Assigned to: RECEIVE®
ARO FRO MRO RRO WARO WIRO WSRO IBC
I)ENR-LAND QUALITY
STI ORMWATER ERN4114"i•ING
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
Rescission Request Form
Please fill out and return this form if you no longer need to maintain your NPDES storm water 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 recission of your NPDES stormwater permit. Prior to the recission of your NPDES stormwater permit, a
site inspection will be conducted.
I. Owner/Operator (to whom all p
Name of legal organizational entity:
Ta lorsville Precast Mc
Street address:
Telephone number:
828-320-3105
2. Industrial Facility (facit'
Facility name:
Taylors recast
Street ad
it correspondence will be mailed):
Legally responsible person as signed in Item (4) below:
City:
128 T Mfg Rd '
City: aState:
Zip de
Ta for
Permit Num er o whit i5 re uest a "
NCG070033
3. Reason for rescission Request
State and zip code:
1 3 —quiieu inrormation. Attach separate sheets if necessary.
® 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:
On date:
�l Other (please explain):
• -LM WctLer air
of cmr-F
le
­-L1 Wulcn eventually disperses into vegatative field if pond
should ever reach overflow. All operatons are conducted under roof. A concrete
washout pit is used to contain concrete washout material. Washout pit is cleaned out
out twice a year. Inspector noted that we should be considered for potential
rescisson.

4. Applicant Certification:
North Carolina General Statute 143-215.6E (i) 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:
1. as an authorized representative, hereby request recission of coverage under the NPDES stormwater Permit for the
7 _ 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:
Title: Pfe's ae pit
'D f0
(Signature of Applicant)
Mail the entire package to: DEMLR — Stormwater Progrz
Depa:
1 a
r-
a eigh,
(Date Signed)
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