NCG080896_RESCISSION REQUEST_20201106

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FOR AGENCY USE ONLY
Division of Energy, Mineral & Land Resources Date Received
Land Quality Section/Stormwater Permitting Program Year I month
I pay
National Pollutant Discharge Elimination System
Environmental FCEI ED
Quality RESCISSION REQUEST FORM
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Please fill out and return this form if you no longer need to maintain your NPDES stornwater permit.
2) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I 5 N I C I G O 8 0 8 9 6 �tA
2) Owner/Facility Information: • Final correspondence will be mailed to the address noted below
Owner/Facility Name PFJ Southeast, LLC
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Facility Contact Joey Cupp
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Street Address 5508 Lonas Drive
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City Knoxville
State TN ZIP Code 37909 _
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County Knox
E-mail Address loey.cupp@pilottrevelcemere:cdm
Telephone No. 865 474-2826
Fax: [phone]
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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
stornwater are contaminated by exposure to industrial activities or materials.
❑ Facility sold to
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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.
Print or type name of person signing above
Please return this completed rescission request form to:
Revised 20183an10
Date / D - 1 9 " 7.Z
Director, Environmental
Title
DEMLR - Stormwater Program
Dept of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612