NCG140128_Dormant Status Initial Request_20240719

FOR AGENCY USE ONLY
NC
ARO FRO MRO RRO WARO WIRO WSRO
Division of Energy, Mineral, and Land Resources Land Quality Section
N CG 140000
Dormant Status Request Form
Please complete this form if you are pursuing a new dormant status designation for a facility.
Directions:
• Print or type all entries on this request form.
• Attach this form to the Stormwater Upload Form by selecting "Dormant Status Initial Request"from the
dropdown list.
• The submission of this form does not guarantee dormant status will be granted. An inspection from the
Division's Regional Office staff will be conducted prior to final determination.
North Carolina General Statute 143-215.6B (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).
Under penalty of law, I certify that:
Q I, as the legally responsible person or authorized representative, request dormant status for the subject
facility.
✓❑ The subject facility is temporarily inactive and all industrial activities have been suspended.
r❑ All stockpiles have been covered, removed, and/or stormwater has been diverted prior to reaching the piles.
O All wastewater collection areas have been cleaned out.
O 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.
Facility Name: Ready Mix Concrete - Butner Plant
Permit Number: NCG140128
Date Facility Went Inactive: 12/31/2022
Printed Name of Person Signing: Ben Hartman
Title: Environmental Manager
j 7/19/24
( gnature) (Date)
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Department of Environmental Duality