NCG140020_Rescission Request_20180730

FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
'•' Land Quality Section/Stormwater Permitting Program Year Month Day
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
N I c I s I I I I I I I N I c I G 11 14 10 10 12 10
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name S&W Ready Mix Concrete Company LLC - Warsaw Plant
Facility Contact Hank Gay
Street Address 344 NC Hwy 50-117
City Warsaw State NC ZIP Code 28398
County Duplin E-mail Address [e-mail]
Telephone No. 910 284-2664 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 1/1 /2003. 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 Date 7/26118
Hank Gay
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 2018Jan10
Environmental Coordinator
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
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