NCG160192_Rescission Request_20190211

Division of Energy, Mineral & Land Resources
j' Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Environmental
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.:w''
T
1) Enter the permit number to which this request applies: �-' _�-
C O7 2ui3
Individual Permit (or) Certificate of Coverage I nl QUAI W
,
N I C I S N C G 1 6 OT 11M % ERWl-F1'ING
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Rogers Group Inc. - Burnsville Asphalt
Facility Contact
Street Address
City
County
Telephone No.
Van Medlock
421 Great Circle Road
Nashville
Davidson
615 780-5781
State TN
E-mail Address
Fax: 615
ZIP Code 37228
[e-mail]
564-5781
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
❑ Facility closed or is closing on . 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: Facility terminated lease with property owner (Trittico Investments, LLC) on December 31, 2017.
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 ►2(5�I$
rVan Medlock Director of Environmental Services
Print or type name of person signing above Title
Please return this completed rescission request form to: DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10