Loading...
HomeMy WebLinkAboutNCG510547_owner (name change)_20240311Facility Name PI LOT #7971 Facility ID#: 00-0-0000034426 Change of Tank Ownership *Owner Listed on Database Prior to Change: SPEEDWAY LLC New Owner's Contact ID: 55549 New Owner's Name: PILOT TRAVEL CENTERS, LLC Date of Transfer: 10/31/2016 Type of Legal Document Received: BILL OF SALE Contact ID of Previous Owner if Different from Database: Previous Owner's Name on Legal Document: Date of Transfer: Type of Legal Document Received: Change of Ownership Package Scanned: X Date Scanned: 5/31/2022 COO Package Updated By: Annette Parker'' Date Entered: 1/13/2017 Financial Responsibility Updated on TIMS: X Mechanism Type: UST-8 Updated on TIMS: X Insurance and Risk Retention Group Holds Released: X Affiliations Ended Affiliations Added Date Orig. COO Package Received: 11/7/2016 Types of Holds Released: FIR: 1/4/2018 Technical: COO: 1/4/2018 NOV: Other: Prim. Oper. Scott J. Fleming 236457 Auth Repr John M. Helms 112241 Reg Oper Manager Manager Joey Cupp 117632 Operator Pilot Travel Centers, LLC 55549 Reg Oper Other Joey Cupp 117632 Owner's Author. Rep. UST-15 Page 2 of 2 FOR TANKS IN CHANGE OF OWNERSHIP OF UST SYSTEM(S) NC V. INSTRUCTIONS FOR NEW UST SYSTEM OWNER • Page 2 must be completed by the new owner" of the underground storage tank (UST) system(s) and acknowledged by a Notary Public • Please attach copies of proof of ownership transfer (e.g., bill of sale) • If signing as an officer of a corporation, representative of a public agency, administrator of an estate, or as having power of attorney, you must provide a copy of the legal document that proves you can legally sign in such capacity • Failure to provide supporting documentation will result in no effective change in ownership status • This form must be submitted along with a UST-8 Form "Notification for Activities Involving USTs" which has been completed by the new owner. 'Pursuant to NCGS 143-215.94A and 15A NCAC 2N .0203, owner means: ..."any person who owns a UST system used for storage, use, or dispensing of regulated substances.", VI. NEW OWNER OF UST SYSTEM(S) VII. LOCATION OF UST SYSTEM(S) Name of Corporation, Individual, Public Agency, or Other Entity Facility Name Pilot Travel Centers, LLC Pilot #7971 Street Address _ Street Address 5508 Lonas Rd. 1343 Rock Barn Rd-A40 City County City County Knoxville Knox Conover Catawba State Zip Code State Zip Code TN 37909 NC 28613 Telephone Number Telephone Number (865) 588-7488 ( ) Federa D or ocI Security Facility ID# (if known) 00-0-0000034426 Number of small (s 3,500 gallons) tanks located at this facility g a Date na Number of large (> 3,500 gallons) tanks located at this f`dC�lity 7�pheclkhere if UST owner is also ❑ c j the owner of the property r U) #, VIII. NOTARY ACKNOWLEDGEMENT FOR NEW OWNER OF UST SYSTEM(S) r — - - 1 c County I, a Notary Public for said County and State, do hereby certify that personally appeared before me this day and acknowledged the due execution oft a foregoing instrument. 01111Iili111;', Witness my half an4Ui6I seal, this the I day of ,u 1 t) J( Y 20 . �%�� i `1ij Nota blic 0 (Official 5eaf);'�'i1V0�``� MY commission expires Aug. s, 2018 My Commission Expires: UST-15 -2- Revised 10/15 DELEGATION OF AUTHORITY Granted to JOEY CUPP Effective January 1, 2016 Expires December 31, 2016 Acting pursuant to a resolution of the Board of Managers of Pilot Travel Centers LLC (the "Company"), duly adopted on August 31, 2001 and October 31, 2006, the undersigned, Mitchell D. Steenrod, Senior Vice President and CFO, does hereby delegate to Joey Cupp, Environmental Compliance Manager of the Company for the period hereinafter specified, the power and authority, in addition to and not in limitation of any other power and authority he may have, acting alone and subject to the restrictions and limitations set forth herein, to sign Environmental documents sent to the State of North Carolina to enter into commitments and to negotiate, execute, deliver, and perform under contracts and do and perform all such other acts and things on behalf of and in the name of the Company, as are necessary and appropriate to accomplish the management, business, and affairs of the Company in the ordinary course of business, subject in any case and in all matters to (i) the control of the President of the Company and (ii) the right of the President of the Company to revoke this power and authority upon written notice to Joey Cupp, a copy of which notice shall be duly filed with the Secretary of the Company ("Delegation"). Joey Cupp is hereby authorized, acting singly, unless provided otherwise below, to negotiate, execute, acknowledge, deliver, and perform under, in the ordinary course of the Company's business, as are necessary and appropriate to accomplish the management, business and affairs of the company in the ordinary course of business subject in any case and in all matters relating to the Enviroiunerrtal Documents which are prepzucdni the regular course of business for the State of North Carolina which include, but is not limited to, the following facilities attached hereto as Exhibit A. Joey Cupp is further authorized to execute, acknowledge, deliver and perform under, in the ordinary course of business, not by limitation but by way of confirmation, the following types of documents: 1. Tank Registrations 2. Tank Notifications 3. Reimbursement Applications 4. Soil and Groundwater Classifications 5. Site Assessment Reports Environmental Delegation of Authority -North Carolina 2016 Page 1 6. Corrective Action Plans 7. North Carolina Operating Permits 8. Discharge Monitoring Reports (NPDES) Permit Monitoring 9. Transfer and accept permits Provided, however, nothing contained in this power shall authorize Joey Cupp to (i) underwrite, warrant, endorse or guarantee the performance, obligation, or other similar undertaking of any person, Company or other entity whatsoever other than subsidiary Companies of the Company; (ii) purchase, sell, convey, exchange or lease real estate, except as expressly provided above; or (iii) underwrite, warrant, endorse or guarantee the debt obligation of any person, Company or other entity whatsoever. Joey Cupp shall be authorized to act for all the facilities listed in the attached Exhibit A and those that may become known in the State of North Carolina in the future as owned or operated by Pilot Travel Centers LLC. In the event additional facilities have been added and this Delegation of Authority is still in full force and effect, Joey Cupp in his position as Environmental Compliance Manager, shall have the authority to notify the State of North Carolina of any additional facilities covered by this Delegation of Authority by a letter addressed to the appropriate department and shall have all the rights assigned to him under this Delegation of Authority in full force and effect as if fast above stated herein on Exhibit A until the expiration of this Delegation of Authority. Joey Cupp shall.be authorized to act hereunder from the effective date hereof only so long as he shall remain an employee of the Company or until such time as this instrument has been revoked, annulled, and set aside by an instrument of revocation filed with the Secretary of the Company, or until December 31, 2016, whichever may first occur. A photocopy of this Delegation of Authority shall serve as the original. IN WITNESS WHEREOF, Mitchell D. Steenrod, the duly authorized Senior Vice President and CFO of the Company, has executed this Delegation of Authority in the County of Knox, State of Tennessee, December °I , 2015, but effective as of January 1, 2016. ATTEST: Mitchell D. Steenrod ArisfiInk Sr. Vice President and CFO Secretary Environmental Delegation of Authority -North Carolina 2016 Page 2 STATE OF TENNESSEE ) SS: COUNTY OF KNOX ) Personally appeared before me, a Notary Public of the State and County aforesaid, Mitchell D. Steenrod, with whom I am personally acquainted and who, upon oath, acknowledged himself to be the CFO and Senior Vice President of Pilot Travel Centers LLC, the above named Company, and that he as such CFO and Senior Vice President, being duly and fully authorized so to do by all necessary corporate action, executed the foregoing instrument for the purposes therein contained, by signing on behalf of the Company by himself as CFO and Senior Vice President. WITNESS my hand and official seal at Knoxville, Tennessee, this 9 day of December, 2015. N ublic •STi'.'.F, My Commission Expires: \� = of : s TENT El _. ` EE —_ C) C%U 1'Jt ( 5 201 �I N OTP PUPi..ic' rrrn,�� Environmental Delegation of Authority -North Carolina 2016 Page 3 UST-15A FOR TANKS IN OWNERSHIP OF UST SYSTEM(S) NC NC DEPARTMENT OF ENVIRONMENTAL QUALITY RETURN DIVISION OF WASTE MANAGEMENT / UST SECTION COMPLETED 1646 MAIL SERVICE CENTER UST-15A FORM RALEIGH, NC 27699-1646 TO: ATTN: REGISTRATION & PERMITTING (919) 707-8171 I. INSTRUCTIONS 'Pursuant to NCGS 143-215.94A and 15A NCAC 2N .0203, owner means: "any person who owns a UST system used for storage, use, or dispensing of regulated substances." If signing as an officer of a corporation, representative of a public agency, administrator of an estate, or as having power of attorney, you must provide a copy of the legal document that proves you can legally sign in such capacity II. OWNER* OF UST SYSTEM(S) III. LOCATION OF UST SYSTEM(S) Name of Corporation, Individual, Public Agency, or Other Entity Facility Name Pilot Travel Centers, LLC Pilot #7971 Street Address Street Address 5508 Lonas Rd. 1343 Rock Barn Rd. - 140 City County City County Knoxville Knox Conover Catawba State Zip Code State Zi Code TN 37909 NC 2�613 Area Code Phone Number Area Code Phone Number (86) 588-7488 © Check here if UST owner ( ) is also the owner of the property where USTs are located Facility I D# (if known) 00-0-0000034426 Federal Tax ID# or Social Security: Number of small (< 3,500 gallons) tanks located at this facility Dat wnership began: 11-1-16 4 Number of large (>3,500 gallons) tanks located at this facility 11-1-16 UST systems Date IV. NOTARY ACKNOWLEDGEMENT FOR OWNER OF UST SYSTEM(S) -{�'\I ' N ' 1 V ca C'M h County 77— C_a • L> �r�11 S MO-u �)� .Y, �f-�va Notary Public for said County and State, do hereby certify that J Zr _74" personally appeared before me this day and acknowledged the due CI" t D _0 execution of th foregoing i st ment. t^z C r� �kr20_L (,6 ---ti7 Witness myr\ar(FancY>jWW sdal, this the day of ovum . j ; SSEE ; m Notary c PU (Official -Seal) • co\� 110" My CommiSSion expireS AU9. 5, 2018 My Commission Expires: UST-15A 10115 UST-1 Page 1 of 2 FOR TANKS IN i CHANGE OF OWNERSHIP OF UST SYSTEM(S) NC NC DEPARTMENT OF ENVIRONMENTAL QUALITY RETURN DIVISION OF WASTE MANAGEMENT 1 UST SECTION COMPLETED 1646 MAIL SERVICE CENTER UST-15 FORM RALEIGH, NC 27699-1646 TO: ATTN: REGISTRATION & PERMITTING (919) 707-8171 I. INSTRUCTIONS FOR PREVIOUS UST SYSTEM OWNER • Pape 1 must be completed by the previous owner' of the underground storage tank (UST) system(s) and acknowledged by a Notary Public • Please attach copies of proof of ownership transfer (e.g., bill of sale) If signing as an officer of a corporation, representative of a public agency, administrator of an estate, or as having power of attorney, you must provide a copy of the legal document that proves you can legally sign in such capacity • Failure to provide supporting documentation will result in no effective change in ownership status 'Pursuant to NCGS 143-215.94A and 15A NCAC 2N .0203, owner means: ..."any person who owns a UST system used for storage, use, or dispensing of regulated substances." 11. PREVIOUS OWNER OF UST SYSTEM{S) III. LOCATION OF UST SYSTEM(S) Name of Corporation, Individual, Public Agency, or Other Entity Facility Name S eedwa ,LLC I Speedway #7971 Street Address I Street Address 500 Speedway Dr. 1 1343 Rock Barn Rd.-140 City County 1 City County Enon Clark 1 Conover Catawba State Zip Code State Zip Code OH 45323 NC 28613 I Telephone Number Telephone Number 732 738-2925 Facility ID# (if known) : 00-0 0000034426 _ (edtl # oOci I S curity #: Signat re ate IV. NOTARY ACKNOWLEDGEMENT FOR PREVIOUS OWNER OF UST SYSTEM(S) t:. C3 t(LZi: County �t i, -l� 1) joia Notary Public for said County and State, do hereby certify that —j 111 S personally appeared before me this day and acknowledged the due execution gfth6lfbtVgq)ng instrument. ` 0 ....A., SFq�''% MEGHA , WILSON 1 WitP�rri rincia%eal,t 20��. STATE OF 01-110 Comm. Expires -_ September 25, 2019 Recorded in NotaryPubfic `\ Clark County yre'OE o� ��. (Official Seya�jiillitt�t»\\\ My Commission Expires: Lv i-r UST-15 - 1 - Revised 10/15 UST 8 NOTIFICATION FOR ACTIVITIES INVOLVING UNDERGROUND STORAGE TANK SYSTEMS (USTs) NC DEQ / DWM / UST SECTION RETURN 1646 MAIL SERVICE CENTER STATE USE ONLY COMPLETED RALEIGH, NC 27699-1646 FORM ATTN: REGISTRATION & PERMITTING TO: PHONE (919) 707-8171 FAX (919) 715-1117 county http://www.wastenotnc.org/web/wm/ Underground Storage Tank (UST) system owners and operators are required by federal and state law to provide notification for all UST systems that were in the ground on or after May 8, 1986, unless taken out of operation on or before January 1, 1974. In addition, registration of commercial USTs in use on or after January 1, 1989 is necessary to comply with state law (N.C.G.S. 143-215.94C). A UST system owner is: (a) in the case of a UST system in use on November 8, 1984, or brought into use after that date, any person who owns a UST system used for storage, use, or dispensing of regulated substances; and (b) in the case of any UST system in use before November 8, 1984, but no longer in use on that date, any person who owned such UST immediately before the discontinuation of its use. A UST system operator is any person in control of, or having responsibility for, the daily operation of a UST system. The primary purpose of this notification form is to obtain and update information on UST system locations, ownership, construction, product stored, leak detection and corrosion protection methods, etc. and to facilitate permitting and the payment of annual operating fees. It is expected that the information provided will be based on reasonably available records, or, in the absence of such records, personal knowledge, belief, or recollection. Which USTs are included? Regulated and/or commercial USTs, including the following: USTs used to store or resell petroleum product (e.g., motor fuels, jet fuels, waste oil, kerosene, varsol, transmission fluid, mineral spirits, gasohol, etc.) • Heating oil USTs > 1,100 gallons (gals) • Farm or residential USTs > 1,100 gals • Emergency generator USTs • Hydraulic lift USTs • Oil -water separator USTs (containing petroleum in amounts > 1 % of tank capacity) • Hazardous substance USTs > 110 gals (e.g., alcohols, naphthalene, dry cleaning fluids, antifreeze, formaldehyde, hexane, etc.) Which USTs are excluded? Certain tanks are not included in these notification requirements. These tanks include the following: small home heating oil and farm tanks (<_ 1,100 gals), large heating oil tanks (> 1,100 gals) if used to heat four or fewer households and located on premises where used, septic tanks, storm water or waste water collection systems, flow -through process tanks, and tanks situated in an underground area (such as a basement, cellar, mine, shaft, vault or tunnel) if the tank is situated upon or above the surface of the floor. INSTRUCTIONS Please type or print all items except signature. This form must be completed by an owner or operator for each facility containing UST systems. If more than four (4) UST systems are owned at a facility, photocopy the necessary additional sheets and staple to this form. Complete sections I through VI.A. and IX completely. Then only complete the applicable sections of VI.B. through VIII. I. OWNERSHIP OF UST SYSTEM Owner Name (Corporation, Individual, Public Agency, or Other Entity) Pilot Travel Centers, LLC Contact Name (if not named above) Joey Cupp Street Address 5508 Lonas Rd. City State Zip Code Knoxville TN 37909 County Knox Phone Number Fax Number 865-588-7488 865-297-1752 ❑ Check here if "Real" Property Owner of Site Type of UST owner (check all that apply): ❑ State Gov't ❑ Local Gov't 0 Private/Corporate ❑ Federal Gov't GSA Facility ID 1 III. TYPE OF NOTIFICATION (check all that apply) El Amendment of a previous registration form. (Complete only the items in the sections that follow that have changed from a previous UST-6 or UST-8 submittal) ❑ Temporary closure (Complete section VII) ❑ Existing Facility with UST system not previously registered (see fee payment instructions at the bottom of Page 6). II. OPERATOR OF UST SYSTEM L� check if same as owner Operator Name (Corporation, Individual, Public Agency, or Other Entity) Contact Name (if not named above) Street Address T ry City State Zip. Code County C;j =- C-1 M Phone Number — rn El Check here if "Real" Property Owner of Site r- , '— un - 1 Fax Numb m -.J ® Change of Ownership A "Change of Ownership" form, UST-15 along with copies of the legal documents showing the transfer of tank ownership (e.g., bill of sale, property deed, etc.) must accompany this form. Failure to complete a UST-15 will result in no effective change of ownership status UST-8 1 Revised 10/13/15 UST-8 NOTIFICATION FOR ACTIVITIES INVOLVING UNDERGROUND STORAGE TANK SYSTEMS (USTs) N� IV. LOCATION OF UST SYSTEM Facility Name or Company Pilot #7971 Indicate number of regulated tanks at this location 4 Street Address 1343 Rock Barn Rd. 140 Indicate total number of tanks at this location 4 City Zip Code Conover 28613 Check box if tanks are located on land within an Indian reservation ❑ or on other Indian lands County Phone Number Catawba Are any UST systems at this facility located El Yes No ❑ County Tax Map Number: within 500 feet of a water supply well? Facility ID (if known): 00-0-0000034426 V. CONTACT PERSON FOR UST LOCATION Name Job Title Phone Number Joey Cupp Sr. Environmental Manager 865-588-7488 VI. DESCRIPTION OF ALL UST OR COMPARTMENT SYSTEMS AT THIS FACILITY A. UST Information Tank/Compartment ID# Tank No. 1 Tank No. 2 Tank No. 3 Tank No. 4 (e.g., A, B, C or 1, 2, 3; If compartment tank 1 A, 113, 1 C, etc. Date of Installation 8/22/1995 8/22/1995 8/22/1995 8/22/1995 Tank Manufacturer Unknown Unknown Unknown Unknown Tank Model Materials of construction DW Steel/FRP DW Steel/FRP DW Steel/FRP DW Steel/FRP If Other (specify) Capacity (gallons) 10,000 12,000 20,000 20,000 If compartment tank, list compartment size. Check if tank is siphon manifolded and enter ❑ / ❑ / ❑ / ❑ / tank # it is manifolded with. Product stored Y Gasoline Gasoline Diesel Diesel If Hazardous substance, Chemical Abstract Service CAS number Other (specify) c� _ Enter one of the following in the space provided: DW' FRP"' (e.g., Xerxes, Containment Solutions), DW' Steel, DW Steel/FRP"` (e.g., ACT-100), @Y/" S1:6 1)4o urethane (e.g. ACT-100-U), DW' Steel/Jacketed (e.g., Permatank, Titan), Other, SW" FRP"' (e.g., Xerxes, Containment Solutions), SW" Steel, SW" Steel/&P"' (,? C T-100), SW" Steel/Polyurethane (e.g., ACT-100-U) 'DW = Double -walled "SW = Single -walled '"FRP = Fiberglass Reinforced Plastic t �_ z Enter one of the following in the space provided: Aviation Gas, Biodiesel (> 20%) - Diesel Mix, Diesel, Ethanol (> 10%) -Gas Mix, Fuel Oil, Gasoline, Hazard-;4. stance, Heating Oil, Kerosene, Motor Oil, Other Non -Petroleum, Other Petroleum, Transmission Fluid, or Used Oil B. Piping System c- Tank No. 1 Tank No. 2 Tank No. 3 T4:No. J Unknown Unknown Unknown Unknown Piping Manufacturer Piping Model Material of Construction' SW FRP SW FRP SW FRP SW FRP If Other (specify) Piping configuration (Pressurized, Suction, Pressurized Pressurized Pressurized Pressurized Euro can Suction If suction, check valve located at? (Tank, Dispenser, or Both Enter one of the following in the space provided: DW' Flex (e.g., APT XP, Environ GeoFlex), DW' FRP (e.g., Ameron Dualoy, Smith Fibercast Red Thread IIA), DW' Metal/Plastic (e.g., PetrofuseZP), DW' PVC, DW' Steel, None, Other, SW" Copper, SW" Flex, SW" FRP, SW" PVC, SW" Steel 'DW = Double -walled "SW = Single -walled "'FRP = Fiberglass Reinforced Plastic UST-8 2 Revised 10/13/15 UST-8 NOTIFICATION FOR ACTIVITIES INVOLVING UNDERGROUND STORAGE TANK SYSTEMS (USTs) C. Under Dispenser Containment (UDC) Enter the dispenser number(s) in each column that will have the same make/model of dispenser UDC. If all dispenser UDCs will be the same then enter "ALL" as the number in column 1 and complete only column 1. Dispensers with the same UDCs only have to be entered in one of the columns with a list of the dispensers that have that model UDC. Dispenser #(s) Dispenser #(s) Dispenser #(s) Dispenser #(s) UDC Manufacturer UDC Model Is UDC Single (SW) or Double Walled (DW)?' Method of monitoring UDC' UDC Material of Construction 3 If Other (specify) ' Enter one of the following choices: SW (single -walled) or DW (double -walled) 2 Enter one of the following choices: Sump Sensor, Vacuum, Pressure, Hydrostatic, or None Enter one of the following choices: Plastic, FRP (Fiberglass Reinforced Plastic), Other D. Leak detection LD l [Check any box or combination of boxes that apply] [Refer to 15A NCAC 2N .0504, .0505, and .09001 Mark all that apply Tank No. Tank No. Tank No. Tank No. Tank Piping Tank Piping Tank Piping Tank Piping a. Inventory control and tank tightness ❑ ❑ ❑ ❑ testin z b. Automatic tank gauging ❑ ❑ ❑ ❑ c. Manual tank gauging' ❑ ❑ ❑ ❑ \ d. Manual tank gauging and tank tightness ❑ ❑ ❑ ❑ testin ° A e. Interstitial monitoring ❑ ® ❑ ® ❑ ® ❑ i. Method of Monitoring Interstice' Hydrostatic Hydrostatic Hydrostatic Hydrostatic f. Statistical inventory reconciliation ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ g. Groundwater monitoring every 14 dayss ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ h. Vapor monitoring every 14 days ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ i. Automatic line leak detectors a i. Mechanical line leak detector ii. Electronic line leak detector ❑ s ❑ Periodic line tightness testing k. Exempt under 40 CFR 280.41 b 2 (iv) (this exemption applies only to ` "European" suctionsystems) ` I. Other state approved method (specify): ry m. Leak detection not required at this facility ❑ ❑ ❑ ❑ ❑ ❑ Y, :-'_ ❑ because: the UST system at this facility is not regulated (e.g., UST system at this �- rn facility stores heating oil for onsite use). n. Leak detection not required at this facility ❑ ❑ ❑ ❑ ❑ ❑ ❑ because: the UST system stores fuel solely for use by emergency power j generators. (If installed prior to 11/1/07) c-n �--s o. Leak detection not required at this facility ❑ ❑ ❑ ❑ ❑ ❑ ❑ because: the UST system at this facility is a wastewater treatment tank system (e.g. oil/water separator tank). Date leak detection method above initiated UST-8 3 Revised 10/13/15 UST-8 NOTIFICATION FOR ACTIVITIES INVOLVING UNDERGROUND STORAGE TANK SYSTEMS (USTs) D. Leak detection (LD) (Continued) Tank No. 1 Tank No. 2 Tank No. 3 Tank No. 4 V-R TLS 350 V-R TLS 350 V-R TLS 350 V-R TLS 350 Monitoring console manufacturer/model Electronic line leak detector manufacturer /model Interstitial sensor manufacturer/model — tank V-R: Inter liq Sens 794 V-R: Inter liq Sens 794 V-R: Inter liq sens 794 V-R: Inter liq Sens 794 Interstitial sensor manufacturer/model — piping Interstitial sensor manufacturer/model — spill prevention equipment Enter the dispenser number(s) in each column that will have the same make/model of interstitial sensor. If all dispenser interstitial sensors will be the same then enter "ALL" as the number in column 1 and complete only column 1. Dispensers with the same interstitial sensors only have to be entered in one of the columns with a list of the dispensers that have that model interstitial sensor. Dispenser #(s) Dispenser #(s) Dispenser #(s) Dispenser #(s) Interstitial sensor manufacturer/model — UDC ' Interstitial monitoring leak detection is required for all UST systems installed on or after 11/1/2007. You must enter one of the following choices - Tank: Vacuum, Pressure, or Hydrostatic; Piping: Sump sensor, Vacuum, Pressure, or Hydrostatic. Interstitial monitoring leak detection is also required for all UST systems that store a hazardous substance or that are located between 100 and 500 feet of a public water supply well or between 50 and 100 feet of any other well used for human consumption or within 500 feet of a protected surface water classified as High Quality Water (HQW), Outstanding Resource Water (ORW), Water Supply I (WS-1), Water Supply II (WS-ll), or Shell Fishing (SA). (The only exception is for single -walled underground petroleum tanks in the locations described above and installed after January 1, 1991 and before May 1, 2000. Owners and operators of these tanks may use enhanced leak detection as a temporary method until January 1, 2016. Enhanced leak detection consists of 0.2 gallon per hour weekly leak rate tests using an automatic tank gauge plus annual sampling of supply wells within 500 feet for constituents of petroleum.) 2 This method can only be used for 10 years after tank installation or upgrade with corrosion protection, whichever is later. Tank tightness tests must be completed at installation and then every five years. 3 This method is only valid for USTs 550-gallon or less in capacity. This method is only valid for USTs 551 to 2,000-gallons in capacity and can only be used for 10 years after tank installation or upgrade with corrosion protection, whichever is later. Tank tightness tests must be completed at installation and then every five years. 5 Can only be used if groundwater is never more than 20 feet from ground surface. s A mechanical or electronic line leak detector is required for all pressurized piping systems. Additionally you must either perform annual line tightness testing or conduct a monthly monitoring method (e.g., statistical inventory reconciliation, interstitial monitoring, or 0.1 gallon per hour tests monthly using an electronic line leak detector). E. Corrosion protection CP [check any method or combination of methods that apply] [Refer to 15A NCAC 2N .0301 and .03021 Tank No. 1 Tank No. 2 Tank No. 3 Tank No. 4 Tank Piping Tank Piping Tank Piping Tank Piping Sacrificial anodes ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Impressed current ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fiberglass Reinforced Plastic (FRP) ❑ ® ❑ ® ❑ ® ❑ Flexible Pipe ❑ V ` \ \ \ \\ Steel/FRP Composite ® \ ® �� \�s ® ® ss\; Steel/Polyurethane Composite ❑ ❑ ❑ � ❑ �� ;�� Steel/Jacketed ❑ ❑ ❑ \ �a ❑ ��❑ \\\ ; `�` Internal lining ❑ 1,1110 ❑ ❑ Other (specify) None ❑ ❑ ❑ ❑ ❑ ❑ C ❑ _` s ❑ Date CP method above installed 8/22/1995 9/1/2995 9/1/1995 9M/1995'' K`. UST-8 4 Revised 10/13/15 UST-8 NOTIFICATION FOR ACTIVITIES INVOLVING UNDERGROUND STORAGE TANK SYSTEMS (USTs) F. Flexible connectors, Submersible pumps, and Riser i es Tank No. 1 Tank No. 2 Tank No. 3 Tank No. 4 Tank Dispenser Tank Dispenser Tank Dispenser Tank Dispenser Flex connector is present' Flex connector is isolated from the ground' If "No", cathodic protection method' Submersible pump (STP) is isolated from round'(pressurized piping only) If "No", cathodic protection method' Riser pipes and/or other metal fittings are isolated from round' If "No", cathodic protection method' Enter one of the following choices: Yes, No z Enter one of the following choices: IC (Impressed Current), SA (Sacrificial Anode), N (None) G. Spill/Overfill Protection Spill Prevention Equipment Type (Enter Catchment Basin, None, or Not Required ' Tank No. 1 Tank No. 2 Tank No. 3 Tank No. 4 Catchment Basin Catchment Basin Catchment Basin Catchment Basin Spill Prevention Equipment Manufacturer Spill Prevention Equipment Model If double -walled, method of monitoring interstice' Date spill prevention listed above installed Overfill Prevention Equipment Type (Enter Automatic shutoff, Alarm at tank, Ball float', None, or Not Required') Ball float Ball float Ball float Ball float o r Overfill Prevention Equipment Manufacturer rn ., . Overfill Prevention Equipment Model C—r r; Date overfill prevention listed above installed 8/22/1995 8/22/1995 8/22/1995 8l�/19 ' Not Required is only valid for USTs that are always filled by transfers that are 25 gallons or less. D ' Enter one of the following choices: Float sensor, Vacuum, Pressure, Hydrostatic, or None72 ' Ball Floats can not be used with coaxial vapor recovery or suction piping systems. :'n H. Stage I Vapor Recovery (For Gasoline USTs only): Combined annual throughput (gallons) Tank No. 1 Tank No. 2 Tank No. 3 Tank No. 4 Coaxial system ❑ ❑ ❑ ❑ Dual point system ® ❑ ❑ Vapor recovery is not required for this UST' ❑ ❑ Date installed ' Stage I vapor recovery equipment must be installed for all applicable gasoline USTs. [Note: the following gasoline USTs are not required to have Stage I vapor recovery: a) tanks that are 550 gallons in capacity or less, b) tanks that are 2,000 gallons in capacity or less and that were installed before July 1, 1979, and c) tanks at facilities that have a combined annual throughput of less than 50,000 gallons per year]. VII. OUT OF OPERATION UST SYSTEMS Date permanently dosed (removed or fill with solid, inert material) Tank No. Tank No. Tank No. Tank No. Date temporary closure began Date temporary closure ended UST-8 5 Revised 10/13/15 UST-8 NOTIFICATION FOR ACTIVITIES INVOLVING UNDERGROUND STORAGE TANK SYSTEMS (USTs) Vill. FINANCIAL RESPONSIBILITY (for Regulated Petroleum USTs ONLY) The financial responsibility regulations (15A NCAC 20) require that owners and operators of regulated petroleum USTs assure the availability of funds to pay for assessment and cleanup costs in the event of a leaking tank'. The payment of annual tank operating fees into the State Trust Funds fulfills a major portion of the financial responsibility requirements. However, to completely fulfill the requirements, additional funds must be assured by one or more of the mechanisms listed below. The amount of additional financial responsibility required (at a minimum) is the sum of the "3rd Party ($100,000.00)" and "Cleanup ($20,000.00)" State Trust Fund deductibles plus $600/tank (scaling factor). The State Trust Funds may not be used to cover the amount of the deductibles. Federal and state governments owning regulated petroleum UST systems are exempt. ® Tank Owner is providing Financial Responsibility ® Tank Operator is providing Financial Responsibility (Check all financial responsibility mechanisms that apply): ❑ Self-insurance ❑ Escrow account ❑ Corporate guarantee ❑ Local government bond rating test ® Insurance and risk retention group coverage ❑ Local government financial test i Policy # UST G28150039 001 ❑ Local government guarantee Insurer Illinois Union Insurance Company c/o ACE Env. Risk ❑ Local government dedicated fund ❑ Surety bond ❑ None ❑ Letter of Credit ❑ Other ❑ Insurance pools 9-1-16 to 9-1-17 Period of Coverage: ® I am attaching proof of financial responsibility and a Certification of Financial Responsibility form. ❑ I have previously submitted proof of financial responsibility and a Certification of Financial Responsibility form to DWM and there have been NO changes made since that submittal. IX. CERTIFICATION AND ACKNOWLEDGEMENT (Read and Sign After Completing Sections I - VII) I certify, under penalty of law, that I have personally examined and am familiar with the information submitted in this and all attached documents; and that based on my inquiry of those individuals responsible for obtaining this information, I believe that the submitted information is true, accurate, and complete. In addition, I certify that all applicable State and Federal UST requirements have been complied with. If signing as an officer of a corporation, representative of a public agency, administrator of an estate, or as having power of attorney, you must provide a copy of the legal document that proves you can legally sign in such capacity. The owner must certify if providing financial responsibility. N Joey Cupp Sr. Environmental Manager Print O ner Aut rized Representative Print Title of Owner or Authorized Representative p _. 11/1/2016 nature Date Signed "'� - f Cr�CD The o rator must certify if providing financial responsibility. C� v Joey Cupp Sr. Environmental Manager cil "E Print Name of Operator or,Authorized Representative Print Title of Operator or Authorized Representative 11 /1 /2016 gnature Date Signed Penalties: Purs nt to N.C.G.S.143-215.94W any UST system owner or operator who knowingly fails to notify or submits false information shall be subject to a civil penalty not to exceed $10,000 per day, per violation. PAYMENT OF ANNUAL UST OPERATING FEES If this form is being used to notify DWM of USTs which have not been previously registered, annual operating fees may be due. Contact us at (919) 707-8171 to determine the amount of fees that are due. A check (made payable to DEQ-UST) for the annual operating fees must be submitted with this form UST-8 6 Revised 10/13/15 BILL OF SALE FOR UNDERGROUND STORAGE TANKS This Bill of Sale is between Speedway LLC, a Delaware limited liability company, with a mailing address of 500 Speedway Drive, Enon, OH 45323 ("Grantor') and Pilot Travel Centers LLC, a Delaware limited liability company, with a mailing address of 5508 Lonas Drive, Knoxville, TN 37909 ("Grantee"). WHEREAS, Grantor, Grantee and PFJ Southeast LLC ("PFJ"') entered into a Contribution Agreement dated June 17, 2016, pursuant to which, Grantor and Grantee contributed certain assets to PFJ (the "Contribution Agreement"). WHEREAS, all capitalized terms used herein, but not defined, will have the meanings given to them in the Contribution Agreement. WHEREAS, in furtherance of the Contribution Agreement, Grantor desires to transfer to Grantee, and Grantee desires to accept, upon the terms of this Bill of Sale and the Contribution Agreement, all of the underground storage tanks and related equipment located at the Speedway Travel Centers as of the Closing Date. The parties, for good and valuable consideration, the receipt and sufficiency of which is acknowledged, agree, as follows: 1. Effective upon the execution of this Bill of Sale, Grantor, subject to the terms of the Contribution Agreement, contributes, assigns, transfers, conveys and delivers to Grantee all of the underground storage tanks and related equipment located at the Speedway Travel Centers as of the Closing Date and Grantee, subject to the terms of the Contribution Agreement, acquires, accepts and assumes, all of Grantor's right, title, obligations and interest in, to and under the underground storage tanks and related equipment located at the Speedway Travel Centers as of the Closing Date. 2, EXCEPT AS SET FORTH IN THE CONTRIBUTION AGREEMENT, GRANTOR MAKES NO WARRANTIES, EXPRESS OR IMPLIED, OR REPRESENTATIONS AS TO THE CONDITION OF THE OF THE UNDERGROUND STORAGE TANKS AND RELATED EQUIPMENT LOCATED AT THE SPEEDWAY TRAVEL CENTERS AS OF THE CLOSING DATE OR ITS SUITABILITY FOR ANY PARTICULAR USE OR PURPOSE AND GRANTEE, BY ITS ACCEPTANCE OF THIS BILL OF SALE, HEREBY ACKNOWLEDGES THAT, SUBJECT TO THE TERMS OF THE CONTRIBUTION AGREEMENT, ACCEPTS THE UNDERGROUND STORAGE TANKS AND RELATED EQUIPMENT LOCATED AT THE SPEEDWAY TRAVEL CENTERS AS OF THE CLOSING DATE "AS -IS." 3. This Bill of Sale is made pursuant to the terms of the Contribution Agreenoent. Nothing contained in this Bill of Sale will be deemed to modify or amend any of the rights or obligations of any party under the Contribution Agreement. In the event of any inconsistency between this Bill of Sale and the Contribution Agreement, the Contribution Agreement shall control as between Grantor and Grantee. 4. This Bill of Sale shall be binding upon the parties hereto and their successors and assigns. IN WITNESS of their agreement, the parties have executed this Bill of Sale as of .2016. WITNESSES: not Name Print Name 07 SPEEDWAY LLC: By: Printed: 84L.an Y Ae its: V (Qs, PILOT TRAVEL CENTERS LLC Bv: control as between Grantor and Grantee. 4. This Bill of Sale shall be binding upon the parties hereto and their successors and assigns. IN WITNESS of their agreement, the parties have executed this Bill of Sale as of Oe lebe,— 31 , 2016. WITNESSES: SPEEDWAY LLC: By: Printed: Its: Print Name PILOT TRAVEL CENTERS LLC Print Name J 1!u,a4l Execution Copy DISCLOSURE SCHEDULES TO CONTRIBUTION, ASSIGNMENT AND ASSUMPTION AGREEMENT AMONG: SPEEDWAY LLC, PILOT TRAVEL CENTERS LLC, AND PFJ SOUTHEAST LLC Dated as of June 17, 2016 Execution Copy These Schedules have been prepared and delivered in connection with the Contribution, Assignment & Assumption Agreement, dated as of June 17, 2016 (the "Agreement"), by and among Speedway LLC, a Delaware limited liability company ("Speedway"), and Pilot Travel Centers LLC, a Delaware limited liability company ("Pilot") and, upon its execution of the Addendum and Joinder to the Contribution Agreement, PFJ SOUTHEAST LLC, a Delaware limited liability company (the "Company"). Information disclosed in one part of a particular section of these Schedules for any purpose shall be deemed disclosed for purposes of any other part of such section as to which the relevance of such information is reasonably apparent on the face of such information. 2 Execution Copy SCHEDULE 2.1(a) Speedway Travel Centers Alabama Store Address 1550 1600 County Road 437, Good Hope, AL 4555 3201 Buttermilk Rd, Cottondale, AL 1549 I-20 & Highway 77, LincoIn, AL**** 3 Florida Store Address 4556 744 E State Road 44, Wildwood, FL 1 Georgia Store Address 4557 11156 Highway 106, CarnesviIle, GA 4558 2111 US Highway, 41 NE, Calhoun, GA 4559 95 Liberty Rd, Villa Rica, GA 4560 2995 Highway 36 W, Jackson, GA 4561 3460 Madison Highway, Valdosta, GA 4562 2607 Scrubby Bluff Rd, Kingsland, GA 6 North Carolina Store Address 6955 1044 Jimmy Kerr Rd, Haw River, NC 6978 801 NC Highway 211 E, Candor, NC 6990 1000 Trucks top Rd, Kenly, NC 6996 2574 W NC Highway 24, Warsaw, NC 7937 907unod, X4 nsville, NCvRlea 7971 1343 Rock Barn Rd, Conover, NC 7976 1.' 16 Charlotte Hwy, Trouu..an, NC 7983 985 Peeler Rd, Salisbury, NC 7996 2700 Chamber Drive, Monroe, NC 9 Execution Copy Pennsylvania Store Address 4563 7833 Linglestown Rd, Harrisburg, PA 1 South Carolina Store Address 4566 2768 East Cherokee Street, Blacksburg, SC 4567 1155 South Anderson Rd, Rock Hill, SC 4568 574 Bettis Academy Rd, Graniteville, SC 4569 15976 Whyte Hardee Blvd, Hardeeville, SC 4576 9587 Charleston Hwy, St. George, SC 4578 10959 State Highway 200, Winnsboro, SC 4579 1300 Burke Rd, St. Matthews, SC* 4580 2221 Sc Highway 773, Prosperity, SC 4581 1340 Sumter Hwy, Bishopville, SC 4584 1504 Highway 38 W, Latta, SC 10 Tennessee Store Address 4596 3663 Roy Messer Highway, White Pine, TN 4597 502 Gordonsville Highway, Gordonsville, TN 4598 507 Highway 309, Niota, TN** 4599 640 Dixie Lee Ave, Monteagle, TN 1577 106 Comfort Ln., Pioneer, TN**** 5 Virginia Store Address 4619 1318 East Lee Highway, Wytheville, VA 4622 2190 Philpott, South Boston, VA 4642 1014 Mt. Olive, Tom's Brook, VA 4649 713 Oakland Circle, Raphine, VA 4651 781 Moores Ferry R, Skippers, VA 4656 4610 County Drive, Disputanta, VA 6 Land Bank CONTRIBUTION, ASSIGNMENT AND ASSUMPTION AGREEMENT AMONG SPEEDWAY LLC, PILOT TRAVEL CENTERS LLC a -, PFJ SOUTHEAST LLC DATED JUNE 17, 2016 CONTRIBUTION, ASSIGNMENT & ASSUMPTION AGREEMENT This Contribution, Assignment & Assumption Agreement (the "Agreement") dated as of June 2016 (the "Agreement'), is made by and among Speedway LLC, a Delaware limited liability company ("Speedway'), and Pilot Travel Centers LLC, a Delaware limited liability company ("Pilot") and, upon its execution of the Addendum and Joinder to the Contribution Agreement, PFJ SOUTHEAST LLC, a Delaware limited liability company (the "Company"). RECITALS WHEREAS, on the date hereof, Speedway and Pilot own and operate certain travel centers within the southeast United States; WHEREAS, Speedway and Pilot desire to contribute and assign certain travel centers and assets, as set forth herein, to the Company; NOW, THEREFORE, in consideration of the premises and the mutual covenants of Speedway, Pilot and the Company, and upon the terms and subject to the conditions hereinafter set forth, Speedway, Pilot and the Company, intending to be legally bound, agree as follows: ARTICLE I DEFINED TERMS Section 1.1 Defined Terms. Capitalized terms used in this Agreement and not otherwise defined shall have the meanings specified therefor below. "Affiliate" of any Person shall mean any other Person directly or indirectly controlling, controlled by, or under common control with, such Person; provided, that, for the purposes of this definition, "control" (including, with correlative meanings, the terms "controlled by" and "under common control with'), as used with respect to any Person, shall mean the possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of such Person, whether through the ownership of voting securities, by Contract or otherwise; provided, however, that unless otherwise indicated, the Company shall not be considered an Affiliate of Speedway or Pilot, nor shall Speedway or Pilot be considered Affiliates of the Company. "Antitrust Authorities" shall mean the Federal Trade Commission, the Antitrust Division of the United States Department of Justice, the attorneys general of the several states of the United States and any other Governmental Entity having jurisdiction with respect to the transactions contemplated hereby pursuant to applicable Antitrust Laws. "Antitrust Filings" means those reports filed in compliance with the Sherman Act, as amended; the Clayton Act, as amended; the HSR Act; the Federal Trade Commission Act, as amended; and all other Laws, Orders, administrative and judicial doctrines that are designed or intended to prohibit, restrict or regulate actions having the purpose or effect of monopolization, 2 respect to the Company, the business conducted by the Company at the Speedway Travel Centers and Pilot Travel Centers. ARTICLE II CONTRIBUTION AND TRANSFER OF ASSETS BY SPEEDWAY AND ASSUMPTION OF SPEEDWAY LIABILITIES Section 2.1 Contribution and Transfer of Assets. Effective on and as of the Effective Time, as defined in Section 4.6, upon the terms and subject to the conditions set forth herein and in consideration of the representations, warranties and agreements of Pilot and the Company contained herein and in the other Transaction Documents, the assumption of the Speedway Assumed Liabilities by the Company, the payment, contribution, transfer and delivery by the Company to Speedway of the consideration set forth in Article IV, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Speedway agrees to contribute, convey, transfer, assign and deliver to the Company, and the Company agrees to unconditionally and absolutely accept and assume from Speedway, the cash payable by Speedway under Sections 2.1(h) and 21(aJ of this Agreement ("Speedway Cash Amount") and all right, title and interest of Speedway, in, to and under all tangible assets, intangible assets, Speedway Contracts, Permits and other rights, wherever located, which are used or held for use primarily in or related primarily to the operation or conduct of Speedway's Travel Center Business (other than the Speedway Excluded Assets and Speedway Excluded Liabilities, which shall be retained by Speedway), whether or not any of such assets has any value for accounting purposes or otherwise, as the same shall exist as of the Effective Time (the "Speedway Transferred Assets"), free and clear of all Liens, other than the Permitted Encumbrances. Without limiting the foregoing, except to the extent provided in Section 2.2, the Speedway Transferred Assets shall include the following: (a) Travel Centers. The retail travel centers (including any standalone QSR operated by Speedway) and undeveloped properties identified on Schedule 2.1(a) hereto (the "Speedway Travel Centers"), including all Speedway Real Property Owned, Speedway Real Property Leased, Speedway Personal Property Owned and Speedway Personal Property Leases which constitutes, or is used or held for use primarily in or related primarily to the operation or conduct of the foregoing, and any additions, improvements, replacements and alterations thereto made as permitted by the terms of this Agreement between the date of this Agreement and the Effective Time. (b) Real Property Owned. All real property identified on Schedule 2.1(b) hereto, together with (i) all rights, privileges, easements, rights of way, licenses, hereditaments, servitudes, use rights and other appurtenances relating thereto; (ii) all right, title and interest in and to any land lying in the bed of any street, road or highway, existing or proposed, in front of or adjoining any of such real property, any award made or to be made with respect to any of such real property by reason of change of grade or the closing of any street, road or highway and all strips and gores of real property abutting or adjoining any of such real property; and (iii) all buildings, structures, improvements, paved parking areas, fixtures and all other appurtenances thereto located on such real property, and any additions, improvements, replacements and alterations thereto made as permitted by the terms of this Agreement between the date of this (e) Bills of Sale. Speedway and Pilot shall have executed Bills of Sale and assignment to the Speedway Transferred Assets and Pilot Transferred Assets, respectively, to Company, in forms mutually acceptable to Speedway and Pilot (each, a `Bill of Sale"). (g) LLC Agreement. Speedway and Pilot shall have filed the Certificate of Formation of the Company in the office of the Delaware Secretary of State, and shall have entered into the LLC Agreement in the form of Exhibit A. (h) Management Agreement. The parties shall have entered into a Management Agreement in the form of Exhibit B (the "Management Agreement"). (i) Addendum and Joinder. The Company shall have executed an Addendum and Joinder to this Contribution Agreement in the form of Exhibit E. 0) Deeds. Speedway and Pilot shall have executed General Warranty Deeds for the Speedway Real Property Owned and Pilot Real Property Owned, respectively, to the Company, in forms mutually acceptable to Speedway and Pilot (each, a "Deed"). (k) Sublease Agreements. Speedway and Pilot shall have executed Sublease Agreements in forms mutually acceptable to Speedway and Pilot, as required by the last clause each of Section 2.1 and Section 3.1, if any. (1) Assignments of Speedway Material Contracts. Speedway and the Company shall have entered into the Assignments of all Speedway Material Contracts, all with the signed consents of third parties to such agreements as required, in forms reasonably acceptable to Pilot. (m) Assignments of Pilot Material Contracts. Pilot and the Company shall have entered into the Assignments of all Pilot Material Contracts, all with the signed consents of third parties to such agreements as required, in forms reasonably acceptable to Speedway. (n) Termination and Modification of Certain Existing Agreements. Speedway and Pilot (i) shall terminate the Lease Agreement relating to motor fuels equipment and related marketing premises and the Deposit Agreement between the parties relating to the Virginia Speedway Travel Centers, both of which are dated September 26, 2014, and (ii) shall amend (x) the two Lease Agreements relating to Motor Fuels equipment and related marketing premises between the parties relating to convenience stores in Virginia and Connecticut, respectively, both of which are dated September 26, 2014, and (y) the Fuel Supply Agreement relating to the Virginia Speedway Travel Centers. The termination of the Deposit Agreement shall include the payment by Pilot to Speedway as required by that agreement, with the understanding that $250,000 of such required payment may be retained by Pilot and paid to Speedway no later than ninety (90) days after the Closing Date. (o) Permits and Licenses. All permits and licenses necessary for normal operation of the Travel Center Business of the Company shall have been issued to the Company. (p) Conversion Schedule. The parties shall have agreed to a written conversion schedule, identifying the timetable for conversion of Speedway Travel Centers ("Conversion 62 IN WITNESS WH�REOF, the undersigned have each set their hand at Clark County, Ohio, effective this i� day of Jyn1Z , 2016. SPEEDWAY LLC, a Delaware limited liability company By: CZ2�� Name: K Title: [PILOT SIGNATURE PAGE FOLLOWS] ?I IN WITNESS WHEREOF, the undersigned has. �set his/her hand at County, effective this - / / day of Icy n^e , 2016. PILOT TRAVEL CENTERS LLC a Delaware limited liability company 72