W. Va. Code R. agency 52, tit. 52, ser. 52-01, app A[1]
WEST VIRGINIA AIR QUALITY BOARD CHARLESTON, WEST VIRGINIA
___________________________________,
APPELLANT'S NAME,
Appellant,
v. Appeal No.
DIRECTOR, DIVISION OF
______________________________________,
DEPARTMENT OF
ENVIRONMENTAL PROTECTION,
Appellee.
NOTICE OF APPEAL
Action Complained Of: The appellant(s) named above respectfully represent(s) that it is aggrieved by (identify the order, failure or refusal, or permit, and give date of the order or permit):
Relief Requested: The appellant therefore prays that this matter be reviewed and that the Board grant the following relief (describe the relief sought):
Specific Objections: The specific objections to the action, including questions of fact and law to be determined by the Board, are set forth in detail in separate numbered paragraphs and attached hereto. The objections may be factual or legal.
Amendment of this Notice of Appeal may be had only by leave of the Board, and only for good cause shown.
Dated this _____ day of ______________, 20_____.
___________________________________
(Signature)
___________________________________
(Address)
___________________________________
___________________________________
(Telephone)
___________________________________
1 This form is offered as guidance to unrepresented parties.
W. Va. Code R. agency 52, tit. 52, ser. 52-01, app A[1]