NCG210461_Rescission Request Form_20220509

FOR AGENCY USE ONLY RECEIVED
Assigned to: 6, CaA-0h
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DEMLRStormwater Program
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.
Directlanc:Print or -type alLentries on this application form. Send the original, signed -application to: NGDEMUt--
Stormwater Program,1612 Mail Service Center, Raleigh, NC 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 permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
Oak Valley Hardwoods, Inc.
Jimmy Lee
Street address:
City:
State and zip code:
6018 Hathaway Lane
Waxhaw
NC 28173
Telephone number:
Email address:
336-906-4103
[e-mail]
2. Industrial Facility (facility requesting rescission):
Facility name:
Oak Valley Hardwoods, Inc
Street address:
68 Snowbird Rd.
City:
State:
Zip Code:
County:
Robbinsville
NC
28771
Graham
Permit Number to which this request applies:
NCG210461
3. Reason for rescission Request
ms is
❑p 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: June 01, 2019
Facility sold.
Sold to:
(please explain):

4. Applicant Certification:
North Carolina General Statute 143-215.66 (1) 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 ($30,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
+❑ 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: Jimmy Lee
Title: -CEO
SW -!!-
(Signature of Applicant)
May 06, 2022
(Date Signed)
Mail the entire package to: DEMLR —Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
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