NCG020923_Rescission Request Incomplete_20211207

©`� • % Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
NCDENRNational Pollutant Discharge Elimination System
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RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
I Month
I Da
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
Mr- 0 6 2021
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Cove rag �RPWilapp 4ND ERMIITy
N C SEJ= N C G 0 2 0 9 2 3 RMITilA1G
2) Owner/Facility Information: a Final correspondence will be mailed to the address noted below
Owner/Facility Name HOM Development, LLC / Bayview Sand Mine
Facility Contact
Street Address
City Manteo
County Currituck
Telephone No. 252-202-1501
State NC ZIP Code 2795�
E-mail Address iamie(a-hatchellconcrete.com
Fax:
3) Reason for rescission request (This is reguired information. Attach separate sheet if necessary):
❑X Facility closed or is closing on 7-1-21 . 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:
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 ^ &Bt4signed by Ken Elliot)
E-ken4 DN Ken EIIloorfl liofl Conwaing,
Ken E I I i ott E=ken�kenobx om
Reason. I afloat to the accuracy and Integrity of Nis
dawmant
Signature LL to.ElaoflconsAng Date November 30,2021
Kenneth Elliott Authorized representative for
Print or type name of person signing above Title HOM Development, LLC
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: [phone] \ FAX: [phone]
An Equal Opportunity \ Affirmative Action Employer