NCG510070_Renewal Application_20210121

ENV] R❑NMENTAL
NEW YORK
January 22, 2021
Mr. Charles H. Weaver
NCDEQ — DWR\Water Quality Permitting Section
NPDES Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
RE: CoC Renewal for NCG510070
Incident # 7489
Dixie Grocery
4730 NC Hwy. 39 South, Gillburg, NC 27536
Dear Mr. Weaver,
emsenv.com
Please accept the following correspondence as our client's intent to renew the NPDES
permit associated with the groundwater remediation system located at the Dixie Grocery
site.
Additional data including a site map depicting the layout of the system's effluent
discharge line has been included along with documentation signed by Dixie Grocery, Inc.
designating EMS Environmental, Inc. as an Authorized Representative.
If you have any further questions, or if you require any additional information please
contact me at [phone].
Sincerely,
EMS Environmental, Inc.
James Dodson
Project Manager
Attachments
Cc: Dixie Grocery, electronic
M:\7023-dixie\NPDES Files\7023 NPDES Permit Rcncw 2021.doc
PENNSYLVANIA
NORTH CAROLINA
EMS ENVIRONMENTAL INC. ■ 1 17 South Hoover Road ■ Ourham, NC 27703-3350 ■ [office] 91 9.596.0470 0 [fax] 91 9.596.0576

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Thomas A. Reeder John E. Skvarla, lli
Governor Director Secretary
NOTICE OF RENEWAL INTENT
[Required by 15A NCAC 02H .0127(d)1; [term definition see 15A NCAC 02H .0103(19)]
Application for renewal of existing coverage under General Permit NCG510000
Existing Certificate of Coverage (CoQ: NCG510 070
(Please print or t)pe)
1) Mailing address of site Owner: (address to of,!rich all correspondence should be mailed
Company Name Dixie Grocery, Inc.
Company Contact Mr. Dennis Poythress
Street Address 4365 NC Highway 39 South
City Henderson State NC ZIP 27-537
Telephone # [phone] Fax #
Cell/Mobile # Email [e-mail]
2) Location of remediation site producing discharge:
Facility Contact Dixie Grocery - Dennis Poythress
Street Address 4730 NC Highway 39 South
City Henderson State NC
County Vance
Telephone # [phone] Fax #
3) System operator / Consultant ID: (if different fi-orn O►t,ner)
Company Name EMS Environmental, Inc.
Street Address 117 South Hoover Road
City Durham State NC
County
Telephone # [phone] Fax #
Email [e-mail]
ZIP 27357-
Page 1 of 2 Revised 911113

NCG510000 Renewal Application
4) Site ranking & ID: GW incident #: 7849
Site Ranking (ifavaitahle): H 765 D
Date of most recent discharge: Aueust 9, 2018
Additional Application Requirements:
The following information must be included in duplicate [original + 1 copy] with this application or
it will be returned as incomplete.
➢ Site map: Clearly showing the path of the remediation system effluent from the site to
its discharge point
➢ Authorization for representatives. If this application will be submitted by a consulting
engineer (or engineering firm), include documentation from the Permittee showing that
the consultant submitting the application has been designated an Authorized
Representative of the applicant.
CERTIFICATIdN
I certify that I am familiar with the information contained in this application and that to the best of my
knowledge and belief such information is true, complete, and accurate.
Printed Name of Person Signing; James Dodson, EMS Environmeutal, Inc.
Title: Project Manager
(Signature �ofApplicant)
North Carolina General Statute 143-215.6 b (i) provides that:
January 22, 2021
(Date Signed)
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 Article 21 or regulations of the Environmental Management Commission implementing that Article, or who
falsifies, tampers with or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under
Article 21 or regulations of the Environmental Management Commission implementing that Article, shall be guilty of a misdemeanor punishable by a
fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001 provides a punishment by a fine of not
more than $25,000 or imprisonment not more than 5 years, or both, for a similar offense.)
This
Notice
of
Renewal
Intent
does
NOT
require a
separate
fee.
The permitted
facility
alreadypays
an annual
fee for coverafze
under NCG510000.
Mail this application and one copy of the entire package to:
NC DENR / DWR /Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 276994617
Attn: Charles Weaver
Page 2 of 2 Revised 9/1/13

March 6, 2006
North Carolina Department of Environment, Health and Natural Resources
Division of Environmental Management
Groundwater Section
P.O. Box 29535
Raleigh, North Carolina 27626-0535
Re: Authorized Representafive of Dixie Grocery, Inc.
Dear Sir/Madam:
This is to certify that EMS Enviromnental, Inc., is au AI1�'FII®II�EII9 II2EPII�S�1�T'&'ATi II� of Dixie
Grocery, Inc., for the purposes of obtaining coverage under NPDES Permit NCG510000.
it,
Dennis PoyffiAs
President
Before une personally appeared �2n,n'� � �i�" to me larowu and Imown to me to be the
person descrked in and who executed the foregoing instrument, and acknowledge to and before me that
M117 u4kK/j executed said instrument for the purposes therein expre
p�0p0�c�A HEw pi��i
WTNESS my 4and offici 1 ea1 this 0 day of �Y agA,D.,20DA e �p 1 ,
Notary Public
My Commission Expires p1��© a
STATE OF neh �1 �A()l Ah COUNTY OF tr U T Aryl �: 'oUB0c'
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