NCG140457_RescissionRequest_20211123

FOR AGENCY USE ONLY
Assigned to: B• C,q SO)
ARO FRO MRO RRO WARD WIRO WSRO
Division of Energy, Mineral, and Land Resources Land Quality SectigpE
National Pollutant Discharge Elimination System q CEIVED
Rescission Request Form NOY 23 N21
Please fill out and return this form if you no longer need to maintain your NPDES stormwater pe WAD
D Q(JALRY
PERMaTi.'6
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.
1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person assigned in Item (4) below:
Crete Solutions LLC
William N. West
Street address:
City:
State and zip code:
2005 Eastwood Road, Suite 200
Wilmington
NC 28403
Telephone number:
Email address:
910-726-1694
[e-mail]
2. Industrial Facility (facility requesting rescission):
Facility name:
Leland Portable Concrete Plant
Street address:
1791 Fletcher Road
City:
State:
Zip Code:
County:
Leland
NC
28451
Brunswick
Permit Number to which this request applies:
0280000812
3. Reason for rescission Request
This is required information. Attach separate sheets if necessa
a 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: July 1, 2020
E3 Facility sold.
Sold to:
On date:
© Other (please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.66 (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:
O 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: William N. West
Title: President
11/18/2021
(Signature of Applicant) (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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