SWA000187_Supplemental Info Review_20230403

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/3/2023 4:58:21 PM (Supplemental Submittal)
Submit by bethany.georgoulias 4/17/2023 11:27:16 AM (Supplemental Info Submittal)
• The task was assigned to bethany.georgoulias 4/3/2023 4:58:22 PM

Submittal from 4/3/2023
Permit Information:
Please orovide soecific oermit details below.
What Type of Permit?
Choose one:
*
NPDES Industrial or MS4 Permit
State Stormwater (Post -Construction) Permit
Other
Permit Number*
SWA000187
Begins with "SW", "NCG", or "NCS"
What DEQ Office is
Reviewer: Please correct if misidentified, close this review form, and reassign task to the appropriate contact.
the Primary Contact?
Central Office
*
Washington Regional Office (Attn: Carl Dunn)
Wilmington Regional Office (Attn: Christine Hall)
Project Name* Circle K - HSD Addition 2723997 - Stedman, NC
Owner/Operator*
Circle K Stores Inc.
County:
Cumberland
Submitter Name:*
Mike Davidson
Who is submitting this information?
E-mail Address:*
[e-mail]
Phone Number*
984-222-1610
Additional E-mail for [e-mail]
Submittal (Optional)
Confirmation:
State Stormwater (Post -Construction) Information Uploads
Choose file type and upload attachment (Reviewer may remove unnecessary submittals)
File Type* Property Deed
File Upload Click the upload button, or drag and drop files to attach
4747 Maxwell Road - Stedman, NC - Property
82.69KB
Deed.pdf
Only PDF files are accepted.
Is this project funded No
with ARPA grant Yes
funds? This question was added 3/19/2023 and will not be answered on submissions prior to that date. Reviewer may
update if known.

Uploads contain NO
Confidential YES
Information * NOTE: The following information cannot be claimed as confidential: the name and address of any permit applicant
or permittee, permit applications, permits, effluent data, information required by NPDES application forms provided
by the Director inclusive of all forms and attachments [Ref. 40 CFR 122.7(b) and (c)].
Notes about the attachments:
* By checking the box and signing box below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of this Supplemental Information form is a "transaction" subject to Chapter 66, Article 40 of the
NC General Statutes (the "Uniform Electronic Transactions Act)
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the Supplemental Information Upload form.
Full Name:* Mike Davidson
Signature:
11,W- � orw! 1111-w
Date Submitted: 04/03/2023

Initial Review
Verify Permit No.* IMPORTANT: REVIEWER SHOULD VERIFY and revise here if necessary.
SWA000187
Who needs a Copy?* Reviewer selections will only be required for offices checked here.
Central Office Staff
Regional Office Stormwater Contact
State Stormwater RO Staff
No Copy Needed
Central Office Reviewer:*
Notifies CO Staff with Email
Jim Farkas
Any Comments or
Added Info for CO
Staff Reviewer?
Review Date* 04/17/2023