NCG160006_Rescission Request_20190604

Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Envirorimewai
Quality RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Receivetl
Year
Month
I Day
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 N I C I G 1 6 0 0 0 6
2) Owner/Facility Information: * Final correspondence will be gaited to the address noted below
Owner/Facility Name BARNHILL CONTRACTING COMPANY
Facility Contact DAVID GLOVER
Street Address 604 EAST NEW BERN ROAD
City KINSTON State NC ZIP Code 28502
County LENIOR E-mail Address [e-mail]
Telephone No. 252 823-1021 Fax:
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
El 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:
NO LONGER NEEDED PLANT SITE HAS BEEN TAKEN DOWN YEARS AGO.
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 C{ ICJ�Q
DAVID GLOVER
Print or type name of person signing above
Please return this completed rescission request form to:
Date 6/4/2019
ASPHALT SERVICES MANAGER
Title
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised 2018Jan10