NCG160075_Rescission Request_20190604

Division 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 [e-mail]
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