NCG140474_Rescission Request_20220719

FOR AGENCY USE O%Y
Assigned to: d�
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RECENED
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GEMLIR'Sior"ater Program
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 stormwater permit.
Directions: Print or type all entries on this application form. Send the original, signed applicatio• NCDEMLR
Stormwater Program,1612 Mail Service Center, Raleigh, NC 27699-1612. The submission of thi. does not
guarantee recession of your NPDES stormwater permit. Prior to the recession of your NPDES stormwd...11111pt.,,...it,
site inspection will be conducted.
1. Owner/ODerator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
Chandler Concrete Company, Inc.
RYAN FOLEY
Street address:
City:
State and zip code:
1006 S. Church St.
Burlington
NC 27215
Telephone number:
Email address:
_
336-2603023
[e-mail]
2. Industrial Facilitv (facility reauestine rescission):
Facility name:
Chandler Salisbury Portable Plant
Street address:
1215 Longs Ferry Rd.
City:
State:
Zip Code:
County:
Salisbury
North Carolina
28146
Rowan
Permit Number to which this request applies:
NCG140474
3. Reason for rescission Request
r ms is requrreu rrnurrnduun. ratacn aepdrdLU Aleep n neLes>dry.
O 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: %u 4
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 ($30,000). 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 N& �e of Person Signing: Ryan Foley
Title: Envirc lintal Specialist
v� 1�,PIZ
(Signatu pplica ate Si ed)
Mail the entire package to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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