NCG140447_Rescission Request_20191014

Division of Energy, Mineral & Land Resources
�.� Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
Energy, Mineral RESCISSION REQUEST FORM
and Land Resources
ENVIRONMENTAL QUALITY
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
RECRVIED
OCT 14 2019
11EINER 1 Awn Q I! I ITS`
.i.y TER PERMITTING
Please fill out and return this form if you no longer need to maintain your NPDES stormwater perms.
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 C G I 1� 4 1 0 1 4 14 1 7
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name: McCarthy Improvement Company/ McCarthy Improvement Iredell County Concrete Plant
Facility Contact John Henkels (original) David Gavlor (current
Street Address 2289 Turnersburg Highway
City Harmony State NC ZIP Code 28625 _
County Iredell E-mail Address [e-mail]
Telephone No. [phone] Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on 5/24/2017 . 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,�y ith the inform fdR contained in this request and to the best of my knowledge and belief
such information is true,. com�tete and acct:frate.
Signature
'Print or type name of person signing above
Please' return this completed rescission request form to:
Date
z'
NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612