NCG020032_Rescission Request_20180621

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources I Date Received
N
' Land Quality Section/Stormwater Permitting Program Year Month De
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
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
IN I C I S I I I N I 0 I 0 0 2 0 0 3 2
2) Owner/Facility Information: • Final correspondence will be mailed to the address noted below
Owner/Facility
Facility Contact
Street Address
City
County
Telephone No.
Unimin CorpGreen Mountain Plant #1
Jeffrey S. Ferguson
136 Crystal Drive
Spruce Pine State NC
Mitchell E-mail Address
828 765-1114 ext. 1602
Fax: 828
ZIP Code 26777
ifergusonQunimin.com
765-4755
3) Reason for rescission request (This is reguired information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 2011 . 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: All processing equipment was removed and entire facility demolished in 2011. Site has remained under dormant status.
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.
oSg Losee
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 20183an10
Date '�Ly Ile
0
V.P. Sustainability & Environment
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612