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HomeMy WebLinkAboutNCG080896_Rescission request_20201028FOR AGENCY USE ONLY Date Received Year Month Day 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 I C I S I I I I I I N I C I G 018 10 18 19 6 2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below Owner/Facility Name PFJ Southeast, LLC Facility Contact Street Address City County Telephone No. Joey Cupp 5508 Lonas Drive Knoxville Knox 865 474-2826 State TN ZIP Code 37909 E-mail Address Joey.cupp@pilottravelcenters.com Fax: 865 297-1752 3) Reason for rescission request (This is required information. Attach separate sheet if necessary): ❑ Facility closed or is closing on . 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: Discharge from oil water separator is confirmed to flow to the on site sanitary lift station. Apex spoke with Mr. Jason Wilson with Salisbury -Rowan Utilities who confirmed that they are aware of the OWS discharge to sanitary. Permit not required for site since OWS does not discharge to on site stormwater. 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. Signatu Print or type name of person signing above Please return this completed rescission request form to: Date Director, Environmental Title DEMLR - Stormwater Program Dept. of Environmental Quality 1612 Mail Service Center Raleigh, North Carolina 27699-1612 Revised 20183an10