NCG030597_Rescission Request_20221205

RECEIVED
FOR AGENCY USE ONLY
Assigned to: 0. COOK DEC o s 2022
ARO FRO MRO RRO WARO WIRO WSRO
"'Al-R-Stormialcr F-,,�zT
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
Rescission Request Form
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
Stormwater Program,1612 Mail Service Center, Raleigh, INC 27699-1612. The submission of this form does not
guarantee recission of your NPDES stormwater permit. Prior to the recission of your NPDES stormwater permit, a
site inspection will be conducted.
1. Owner/Operator (to whom all Dermit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
Haloore Group Inc
Jeff Dreyer
Street address:
City:
State and zip code:
101 Gates Lane
Jefferson
NC 28640
Telephone number:
Email address:
336-846-8010
)[e-mail]
2. Industrial Facility (facility requesting rescission):
Facility name:
American Emergency Vehicles, Inc.
Street address:
165 Amedcan Way
City:
State:
Zip Code:
County:
Jefferson
NC
28640
Ashe
Permit Number to which this request applies:
NCG030597
3. Reason for rescission Request
This is required information. Attach separate sheets if necessary
® Facility is closed or closing. All industrial activities have ceased such that no discharges of stormwater are contaminated
by exposure to industrial activities or materials.
Date closed/closing:
M Facility sold.
Sold to: Kirk East LLC; 4411 SE 169th Court, Vancouver, WA 98683
On date: February 17, 2021
® Other (please explain):
AEV leased the facility since 2117/2021. AEV dosed, moved all equipment, and ceased operations at the facility on November 17, 2022.

4. Applicant Certification:
North Carolina General Statute 143-215.6E (i) provides that: Any person who knowingly makes any false statement,
representation, or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
❑O I, as an authorized representative, hereby request recission 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.
Printed Name of Person Signing:
Title: Director of Operations
11122I2022
(Date Signed)
the entire package to: EMIR Stormwater Program
D-eparfment of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 2 of 2