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HomeMy WebLinkAboutNCG160075_Rescission Request_20190604Division of Energy, Mineral & Land Resources Land Quality Section/Stormwater Permitting Program Kl�rlv National Pollutant Discharge Elimination System Environmertat Quality RESCISSION REQUEST FORM FOR AGENCY USE ONLY Date Receivetl Year Month 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 I I I I I N I C I G 1 6 0 0 7 5 2) Owner/Facility Information: • Final correspondence will be mailed to the address noted below Owner/Facility Facility Contact Street Address City County Telephone No. BARNHILL CONTRACTING COMPANY DAVID GLOVER HWY 158 CURRITUCK State NC ZIP Code CURRITUCK E-mail Address dglover@barnhillcontracting.mm 252 823-1021 Fax: 3) Reason for rescission request (This is required information. Attach separate sheet if necessary): 0 Facility closed or is closing on 2014 . 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. Q Other: SITE SOLD 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 r-\XNVCGY LJ/1� DAVID GLOVER Print or type name of person signing above Please return this completed rescission request form to: Date 6/42019 ASPHALT SERVICES MANAGER Title DEMLR - Stormwater Program Dept. of Environmental Quality 1612 Mail Service Center Raleigh, North Carolina 27699-1612 Revised 20181an10