NCG020923_Rescission Request_20220127

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Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date
Received
Year
I Month
Day
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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 S I I I I I I N I C I G 1012 0 1912 13
2) Owner/Facility Information: • Final correspondence will be mailed to the address noted below
Owner/Facility Name HOM Development, LLC / Bavview Sand Mine
Facility Contact Jamie B. Hatchell
Street Address PO Box 2405 / 1002 Driftwood Drive
City Manteo
County Currituck
Telephone No. 252-202-1501
State NC ZIP Code
E-mail Address iamiel
Fax:
3) Reason for rescission request (This is required 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 accurate.
Signature
`\
Print or type name of person signing above
Date December 14, 2021
Manager, HOM Development, LLC
Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
RECEIVED Raleigh, North Carolina 27699-1612
JAN 2 7 2022 1612 Mail Service Center, Raleigh, North Carolina 27699-1612
Phone: 91 M07-63001 FAX: [phone]
DENR•LAND QUALITY An Equal Opportunity 1 Affirmative Action Employer
STORMWATER PERMITTING