NCG080162_Rescission Request_20230510

RECEIVED
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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 storm water permit.
Directions: Print or type all entries on this application form. Send the original,signed application to: NCDEMLR
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:
Love's Travel Stops&Country Stores Caleb Harrison
Street address: City: State and zip code:
10601 N Pennsylvania Avenue Oklahoma City 73120
Telephone number: Email address: „
405-308-8516 [e-mail]
2. Industrial Facility(facility requesting rescission):
Facility name:
Love's Travel Stop#412
Street address:
3948 Hodges Chapel Road
City: State: Zip Code: County:
Dunn NC 28334 Harnett
Permit Number to which this request aplplies:
NCGO80000 AICIG 0TOI `oc
3. Reason for rescission Request
This is required information.Attach separate sheets if necessary.
E3 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:
0 Facility sold.
Sold to:
On date:
El Other(please explain):
Facility is currently being redeveloped. Existing oillwater separator has been removed and replacement separator will discharge to municipal sanitary sewer.

4. Applicant Certification:
North Carolina General Statute 143-215.66(i)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($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
O 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: Caleb Harrison
Title: Divisional Environmental Manager-Love's
C� �i� SI�f 2023
(Signature of Applicant) (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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