NCG140486_Rescission Request_20230301

FOR AGENCY USE ONLY
Assigned to: ritt0
ARO FRO MRO RRO WARO WIRO WSR
0EWit.mmWatnt Pf0781111
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 stormwoter 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.
1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal grganization I entity:
6641f,Co
Legall esponsible person as signed in Item (4) below:
l�
ti
r/e
Street address:
' s s
Cit :
State and zip code:
t,� o�
Telephone number-
EmaiI d re
2. Industrial Facility (facility requesting rescission):
Facility name: j. L
C 7 SITf�
Street address. "2701
kvv
City: State: Zip Code:
27302
County:
orb o�;��
�,#A C ee
Permit Number to which this reques a plies:
bM
C _
3. Reason for rescission Request
This required information. Attach separate sheets if necessary
p 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:
E3 Facility sold.
Sold to:
On date:
❑Other (please explain):

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.
and enalty of law, I certify that:
Nd 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: 1. o
!'ey
Title: �/1V,tC/I It�G I 3�er`c,1rS/,y
(Date Signed)
Mail the ent pa age to: DEMLR — Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 2 of 2

p'1� �A TuAt.
'1
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCGIL40000 ZYC-I&A
CERTIFICATE OF COVERAGE No.NCG140486 Fleale .
STORMWATER DISCHARGES AND WASTEWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision -of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North. Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Chandler Concrete Company Inc
is hereby authorized to operate wastewater treatmentsystem(s) and discharge
stormwater and/or wastewater (as per original approval or subsequent modifications),
from a facility located at:
Mebane Plant #610 - adjacent site
-29%Senator Ralph Scott Pkwy
2764 Mebane
Alamance County
to receiving waters designated as Back Creek; class WS-V;NSW waters in the Cape Fear
River Basin(s), in accordance with the effluent limitations, monitoring requirements, and
other conditions.set forth.in General Permit No. NCG140000which can be downloaded by
entering "dgq nc gov/SW-industrial" in the browser window and navigating to the "NPDES
Stormwater General. Permits" web page.
This certificate of coverage shall become effective July 1, 2022.
This Certificate of Coverage shall remain in effect for the duration of the General Permit or
until rescinded.
for Brian Wrenn.
Director, Division of Energy, Mineral and Land Resources
By the Authority of the Environmental Management Commission