NCG210455_Rescission request-20210322

FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Q_ualilyRESCISSION REQUEST FORM
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 C S _.. N I C I G' L I C) S
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Na
Facility Contact
Street Address
City
County
Telephone No.
Oak Valley Hardwoods, Inc.
Jimmy Lee
127 Romarco Rd,
Morganton
Burke
[phone]
State NC ZIP Code 28655
E-mail Address [e-mail]
Fax: NA
3) Reason for rescission request (This is reQuired information. Attach separate sheet if necessary):
❑✓ Facility closed or is closing on 1/21/21 . 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 with the information contained in this request and to the best of my knowledge and belief
such information is true, complete and accurate.
t
Signature AavmDate 03/18/2021
Jimmy Lee CEO
Print or typofname of person signing above Title
Please return this completed rescission request form to
Revised 20181an10
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612