SW3150906_CURRENT PERMIT_20151016

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
DOC TYPE CURRENT PERMIT
APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE/
YYYYMMDD

Pat McCrory
Governor
NC®ENR
North Carolina Department of Environment and Natural Resources
October 16, 2015
Mr. Steven P. Augustine, Asst. VP/Asst. Secretary
Sheetz, Inc.
5700 Sixth Avenue
Altoona PA 16602
Subject: Stormwater Permit No. SW31509O6
Sheetz, Inc. Statesville, INC
Dear Mr. Augustine:
Donald R. van der Vaart
RECEIVE®tary
OLT282015
DENR�D
Land Qua* Section R
Mooresv#le Regime al c@
The Division of Energy, Mineral, and Land Resources (DELMR), received a complete Stormwater
Management Permit Application for the subject project on September 24, 2015. Staff review of the
plans and specifications has determined that the project, as proposed, will comply with the
Stormwater Regulations set forth in Title 15A NCAC 2H.1OOO and Session Law 2006-246. We are
forwarding Permit No. SW315O906, dated October 14, 2015, for the construction, operation and
maintenance of the subject project and the stormwater system. This permit shall be effective from the
date of issuance until October 13, 2023, or until rescinded and shall be subject to the conditions and
limitations as specified therein, and does not supersede any other agency permit that may be required.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right
to request an adjudicatory hearing by filing a written petition with the Office of Administrative
Hearings (OAH). The written petition must conform to Chapter 150B of the North Carolina General
Statutes. Per NCGS 143-215(e) the petition must be filed with the OAH within thirty (30) days of
receipt of this permit. You should contact the OAH with all questions regarding the filing fee (if a filing
fee is required) and/or the details of the filing process at 6714 Mail Service Center, Raleigh, NC 27699-
6714, or via telephone at 919-431-3000, or visit their website at www.NCOAH.com. Unless such
demands are made this permit shall be final and binding.
This project will be kept on file at the Mooresville Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Mike Randall at [phone]; or
[e-mail].
Sincerely,
l
for Tracy E.
Davis, PE, CPM, Director
CC: SW31509O6 File, Mooresville Regional Office
ec: Brandon Pritchard, City of Statesville
Michael Ellis, LE&D Professionals, PC
Division of Energy, Mineral, and Land Resources
Energy Section • Geological Survey Section • Land Quality Section
1612 Mail Service Center, Raleigh, North Carolina 27699.1612.919-707-9200 / FAX: [phone]
512 North Salisbury Street, Raleigh, North Carolina 27604 • Internet: http://portal.ncdenr.org/web/Ir/
An Equal Opportunity 1 Affirmative Action Employer - 50% Recycled 110% Post Consumer Paper

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State Stormwater Permit
Permit No. SW3150906
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General StatutNorth Carolina as amended, and other applicable Laws, Rules, and Regulation s j
PERMISSION IS HEREBY GRANTED TO CT &O
2
Sheetz, Inc.
at 1520 Salisbury Highway in Iredell County
FOR THE
71 �F,IA 8eolp
ce
construction, operation and maintenance of one sand filter in compliance with the
provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred to as
the "stormwater rules') and the approved stormwater management plans and
specifications and other supporting data as attached and on file with and approved by
the State and considered a part of this permit.
This permit shall be effective from the date of issuance until October 13, 2023, and
shall be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. The sand filter is approved for the management of stormwater runoff as
described in the application documents and as shown on the approved plans.
3. All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
4. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
5. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
II. SCHEDULE OF COMPLIANCE
During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
Page 1 of 4

State Stormwater Permit
Permit No. SW3150906
2. The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted sand filter functions at optimum efficiency. The approved
Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
:c. Mowing and re -vegetation of slopes and the filter strip.
.. ,r^rt
d > ' Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
4i ,= f. Debris removal and unclogging of all drainage structures, level spreader,
filter media, planting media, underdrains, catch basins and piping.
g. Access to the cell and outlet structure must be available at all times.
-;1
3. Records,of maintenance activities must be kept for each permitted BMP. The
J'repo'rts will indicate the date, activity, name of person performing the work and
d;`4hat'actions were taken.
4..,p' "'The permittee shall submit an annual summary report of the maintenance and
inspection records for the sand filter. The report shall summarize the inspection
dates, results of the inspections, and the maintenance work performed at each
inspection.
5. The sand filter shall be constructed in accordance with the approved plans and
specifications, the conditions of this permit, and with other supporting data.
6. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the sand filter certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A
modification may be required for those deviations.
7. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
8. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
9. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of eight years from the date of the completion of
construction.
Page 2 of 4

State Stormwater Permit
Permit No. SW3150906
10. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form signed by both parties, to the
State, accompanied by the supporting documentation. The approval of this
request will be considered on its merits and may or may not be approved.
The permittee is responsible for compliance with all permit conditions until such
time as the Division approves a request to transfer the permit.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the State, in accordance with
North Carolina General Statute 143-215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation
of nuisance conditions, the Permittee shall take immediate corrective action,
including those as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DENR Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
7. The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
8. Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
Page 3 of 4

State Stormwater Permit
Permit No. SW3150906
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Session Law 2006-
246, Title 15A NCAC 21-1.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division in writing of any name, ownership or
mailing address changes at least 30 days prior to making such changes.
12. The permittee shall submit a renewal request with all required forms and
documentation at least 180 days prior to the expiration date of this permit.
Permit issued this the 16"' day of October, 2015.
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

State Stormwater Permit
Permit No. SW3150906
Sheetz, Inc.
1520 Salisbury Highway in Iredell County
Designer's Certification
I, , as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/
full time) the construction of the project,
(Project Name)
for (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
cc: NCDENR-DEMLR Regional Office
Page 1 of 1

DWQ USE ONLY
' Date Re eived
Fee Paid
Permit Number
Applicable R l s: ❑ Coastal SW -1995 ES Coastal SW - 2008 ❑ Ph 11- Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ M mt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STORMWATER MANAGEMENT PERMIT APPLICATION
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name -should be co S t with project name on
specifications, letters, operation and maintenance agreements, etc.): `_oo
2. Location of Project (street address):
City:Statesville County:In
3. Directions to project (from nearest major intersection):
7ip:28677
4. Latitude:35° 46' 07" N J1 Longitude:80° 51' 16" W of the main entrance to the project.
II. PERMIT INFORMATION:.
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tReneoals with modifications also requires SWU-102 - Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit number , its issue date (if known) , and the status of
construction: []Not Started ❑Partially Completed* []Completed* *provide a designer's certification
2. Specify the type of project (check one):
❑Low Density ®High Density ❑Drains to an Offsite Stormwater System []Other
3. If this application is being submitted as the result of a previously returned application or a letter from DWQ
requesting a state stormwater management permit application, list the stormwater project number, if
assigned, and the previous name of the project, if different than currently
proposed,
4. a. Additional Project Requirements (check applicable blanks; information on required state permits can be
obtained by contacting the Customer Service Center at 1-877-623-6748):
❑LAMA Major
❑NPDES Industrial Stormwater
®Sedimentation/Erosion Control: 3.74 ac of Disturbed Area
0404/401 Permit: Proposed Impacts
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit:
5. Is the project located within 5 miles of a public airport? ZNo LjYes
If yes, see S.L. 2012-200, Part VI: http�//12ortal.ncdenr.org/web/­wq/wslsuZstatesw/rules laws
.—FomrSWtf i01—Version 06Aug2012 Page I of 6

III. CONTACT INFORMATION
1. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the proiect):
Applicant/ Organization: Sheetz. Inc.
Signing Official & Title:Steven P. Augustine, Asst. VP/Assistant Secretary
b.Contact information for person listed in item I above:
Street Address:5700 Sixth Ave.
City:Altoona State:PA Zip:16602
Mailing Address (if applicable):Same
City: State: Zip:
Phone: (336 ) 978-1028 Fax: ( )
Email:
c. Please check the appropriate box. The applicant listed above is:
❑ The property owner (Skip to Contact Information, item 3a)
❑ Lessee* (Attach a copy of the lease agreement and complete Contact Information, item 2a and 2b below)
® Purchaser* (Attach a copy of the pending sales agreement and complete Contact Information, item 2a and
2b below)
❑ Developer* (Complete Contact Information, item 2a and 2b below.)
2. a. Print Property Owner's name and title below, if you are the lessee, purchaser or developer. (This is the
person who owns the property that the project is located on):
Property Owner/Organization: Billy R. Moose
Signing Official & Title:Billy R. Moose, Owner
b. Contact information for person listed in item 2a above
Street Address:224 E. Lackev Farm Rd.
City:Stony Point State:NC Zip:28678
Mailing Address (if applicable):Same
City: State: Zip:
Phone: ( ) Fax: ( )
3. a. (Optional) Print the name and title of another contact such as the projects construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization: Sam Smith - Sheetz. Inc.
Signing Official & Title:Sam Smith
b.Contact information for person listed in item 3a above:
Mailing Address:3472 Grandview Crossing Lane
City:Pfafftown State:NC Zip:27040
Phone: (336 ) 978-5354 Fax:
Email:[e-mail]
4. Local jurisdiction for building permits: Statesville, NC
Point of Contact:Brendon Pritchard Phone #: (704 ) 878-3552
Form SWU-101 Version 06Aug2012 Page 2 of

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The stormwater runoff will be conveyed through a storm pipe system to a sediment forebay, an open sand
filter and a normally dry detention basin and discharge to an existing storm pipe system.
2. a. If claiming vested rights, identify the supporting documents provided and the date they were approved:
❑ Approval of a Site Specific Development Plan or PUD Approval Date:
❑ Valid Building Permit Issued Date:
❑ Other: Date:
b.If claiming vested rights, identify the regulation(s) the project has been designed in accordance with:
❑ Coastal SW - 1995 ❑ Ph 11 - Post Construction
3. Stormwater runoff from this project drains to the Yadkin Pee -Dee River basin.
4. Total Property Area: 4.36 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area':4.36 acres
Total project area shall be calculated to exclude the following the normal pool of impounded structures, the area
between the batiks of streams and rivers, the area below the Nornal High Water (NHW) line or Mean High Water
(MHW) title, and coastal wetlands landward from the NHW (or MHM line. The resultant project area is used to
calculate overall percent built upon area (BUA). No -coastal wetlands landward of the NHW (or MHW) line may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 =
9. How many drainage areas does the project have? 1 (For high density, count 1 for each proposed engineered
stonnwater BMP. For low density and other projects, use 1 for the whole property area)
10. Complete the following information for each drainage area identified in Project Information item 9. If there
are more than four drainage areas in the project, attach an additional sheet with the information for each area
provided in the same format as below.
Basin Information
DrainalzeAreaA
Drains e Area _
Drains e Area -
Drains e Area _
Receiving Stream Name
Third Creek
W S-37
Stream Class
C
Stream Index Number *
12-108-20-4
Total Drainage Area (so
37462
On -site Drainage Area (so
37462
Off -site Drainage Area (so
0
Proposed Impervious Area** (so
32234
Impervious Area** total
86
-Im ervious'Surface Area
Drainage Area A
Drainage e Area _
Drainage Area
-Drains e Area
On -site Buildings/Lots (so
5316
On -site Streets (so
On -site Parking (so
23807
On -site Sidewalks (so
1500
Other on -site (so
1611
Future (so
Off -site (so
Existing BUA*** (so
Total (so:
32234
Stream Class and Index Number can be determined at: lnttpl/portal.ncdenr.org eb/wq(ps/csu/classifications
Form SWU-101 Version 06Aug2012 Page 3 of 6

"* Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Report only that amount of existing BUA that will remain after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
11. How was the off -site impervious area listed above determined? Provide documentation.
Projects in Union County: Contact DWQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent slormwater requirements as per 15A NCAC 02B .0600.
V. SUPPLEMENT AND O&M FORMS
The applicable state stormwater management permit supplement and operation and maintenance (O&M) forms
must be submitted for each BMP specified for this project. The latest versions of the forms can be downloaded
from http7//­portal.ncdenr.org/web/wq/wslsu/bmR-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Water Quality (DWQ).
A complete package includes all of the items listed below. A detailed application instruction sheet and BMP
checklists are available from http //portal ncdenr or¢/web/wq/ws/su/statesw/forms does. The complete
application package should be submitted to the appropriate DWQ Office. (The appropriate office may be
found by locating project on the interactive online map at http'//Aortal ncdenr org/web/wq/ws/su/maps.)
Please indicate that the following required information have been provided by initialing in the space provided
for each item. All original documents MUST be signed and initiated in blue ink. Download the latest versions
for each submitted application package from http'//portal.ncdenr.org/ web/ wq /ws/su /statesw/formsdots.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
Form. (if required as per Part VII below)
3. Original of the applicable Supplement Form(s) (sealed signed and dated) and O&M
agreement(s) for each BMP.
4. Permit application processing fee of $505 payable to NCDENR. (For an Express review, refer to
n//www envhelp org/pages/onestopexpress html for information on the Express program
the associated fees. Contact the appropriate regional office Express Permit Coordinator for
additional information and to schedule the required application meeting.)
5. A detailed narrative (one to two pages) describing the stormwater treatment/managementfor
the project. This is required in addition to the brief summary provided in the Project
Information, item 1.
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the'h
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
I. Scale.
g. Revision number and dates.
h. Identify all surface waters on the plans by delineating the normal pool elevation of
impounded structures, the banks of streams and rivers, the MHW or NHW line of tidal
waters, and any coastal wetlands landward of the MHW or NHW lines.
• Delineate the vegetated buffer landward from the normal pool elevation of impounded
structures, the banks of streams or rivers, and the MHW (or NHW) of tidal waters.
i. Dimensioned property/project boundary with bearings & distances.
j. Site Layout with all BUA identified and dimensioned.
k. Existing contours, proposed contours, spot elevations, finished floor elevations.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
Form SWU-101 Version 06Aug2012 Page 4 of 6

9.
10.
TL
m. Wetlands delineated, or a note on the plans that none exist. (Must be delineated by a
qualified person. Provide documentation of qualifications and identify the person who
made the determination on the plans.
n. Existing drainage (including off -site), drainage easements, pipe sizes, runoff calculations.
o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
Copy of any applicable soils report with the associated SHWT elevations (Please identify _
elevations in addition to depths) as well as a map of the boring locations with the existing
elevations and boring logs. Include an 8.5"x1l" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
include the soil type, expected infiltration rate, and the method of determining the infiltration rate.
(Infiltration Devices submitted to WiRO: Schedule a site visit for DWQ to verifij the Sl IW P prior
to submittal, [phone].)
A copy of the most current property deed. Deed book:1028 Page No: 873 _
For corporations and limited liability corporations (LLC): Provide documentation from the NC _
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1 a, 2a, and/or 3a per 15A NCAC 211.1003(e).
The corporation or LLC must be listed as an active corporation in good standing with the NC
Secretary of State, otherwise the application will be returned.
http7//www.secretary.state.nc.usICorporations/­­CSearch.aspx
VIL DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all subdivisions, outparcels, and future development, the appropriate property restrictions and protective
covenants are required to be recorded prior to the sale of any lot. If lot sizes vary significantly or the proposed
BUA allocations vary, a table listing each lot number, lot size, and the allowable built -upon area must be provided
as an attachment to the completed and notarized deed restriction form. The appropriate deed restrictions and
protective covenants forms can be downloaded from
http //portal ncdenr org/web/wq/ws/su/statesw/forms dots. Download the latest versions for each submittal.
In the instances where the applicant is different than the property owner, it is the responsibility of the property
owner to sign the deed restrictions and protective covenants form while the applicant is responsible for ensuring
that the deed restrictions are recorded.
By the notarized signature(s) below, the permit holder(s) certify that the recorded property restrictions and
protective covenants for this project, if required, shall include all the items required in the permit and listed
on.the forms available on the website, that the covenants will be binding on all parties and persons claiming
under them, that they will run with the land, that the required covenants cannot be changed or deleted
without concurrence from the NC DWQ, and that they will be recorded prior to the sale of any lot.
VIII. CONSULTANT INFORMATION AND AUTHORIZATION
Applicant: Complete this section if you wish to designate authority to another individual and/or firm (such as a
consulting engineer and/or firm) so that they may provide information on your behalf for this project (such as
addressing requests for additional information).
Consulting Engineer:Michael A. Ellis
Consulting Firm: LE & D Professionals PC
Mailing Address:110 Exchange St.
City:Danville
Phone: [phone]
Email:[e-mail]
State:Va. Zip:24541
Fax: ( )
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type name of person listed in Contact Information, item 2a) Bilhi R. Moose Owner certify that I
own the property identified in this permit application, and thus give permission to (print or type name of person
listed in Contact Information, item la) Steven P. Augustine with (print or type name of organization listed in
Contact Information, item la) Sheetz Inc. to develop the project as currently proposed. A copy of
the lease agreement or pending property sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Form SWU-101 Version 06Aug2012 Page 5 of 6

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DWQ Stormwater permit reverts back to
me, the property owner. As the property owner, it is my responsibility to notify DWQ immediately and submit a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Date: 7_/6 - 701 5—
i
a Notary Public for the State of AG. %I, �' 0?r,� nACounty of
t A_p A.n c1Z do hereby certify that 3 o GS ' personally appeared
before me this&I day of Q r+ �Jl 2 Q) J , and acknowle ge the d execution of the application for
a Stormwater permit. Witness my hand and official seal,n
SEAL
My commission expires �� �� a C, acl
X. APPLICANT'S CERTIFICATION
I, (print or hjpe name of person listed in Contact Information, item ]a)
certify that the, information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective covenants will be recorded, a id that th proposed project complies with the requirements of the
applicable stormwaterrider 15A >"C 2H�0e0 and any other applicable state stormwater requirements.
Date: 9 - f D - 123'
f C
], f\r 1 ror 1� 7c�lYnrn�y , a Notary Public /for the State of CnnSJ�n ' r. ,County of
1�10-. t , do hereby certify that ��e✓'2->1� '`\L -ow personally appeared
before me this LCK+day of '�Sz C¢MC and acknowledge the due execution of the application for
c
a stormwater permit. Witness my hand and official seal, a
COMMONWEALTH OF PENNSYLVANIA
SEAL NOTARIAL SEAL
Jennifer D. Schramke, Notary Public
City of Altoona, Blair County
My Commission Expires April 7, 2019
MEMBER, PENNSYLVANIA ASSOCIATION OF NOTARIES
My commission expires
Form SWU-101 Version 06Aug2012 Page 6 of 6

{PARiAi
w:- BUSINESS CORPORATION
ANNUAL REPORT
NAME OF 1USINESS CORPORATION: Sheetz Inc.
FISCAL YEAR ENDING: 913012014
SECRETARY OF STATE CORPORATE Ill NUMBER: 0597312
NATURE OF BUSINESS: Retail Convenience Store
REGISTERED AGENT: CT Corporation System
REGISTERED OFFICE MAILING ADDRESS: 150 Fayetteville St., Box 1011
Raleigh, NC 27601-2957
&Filed Annual Report
5345086
Do not data enter manually.
STATE OF INCORPORATION: PA
REGISTERED OFFICE STREET ADDRESS: 150 Fayetteville St., Box 1011
Raleigh, NC 27601-2957 Wake County
PRINCIPAL OFFICE TELEPHONE NUMBER: [phone]
PRINCIPAL OFFICE MAILING ADDRESS: 5700 Sixth Avennue
Altoona, PA 16602-1111
PRINCIPAL OFFICE STREET ADDRESS: 5700 Sixth Avennue
Altoona, PA 16602-1111
PRINCIPAL OFFICERS:
Name: Stephen C Sheetz Name: Stanton R Sheetz Name: Randall A Sheelz
Tide: Chairman 7711e: Chairman Of The Board Title: Vice President
Address: Address: Address:
5700 ,Sixth Ave 5700 Sixth Ave 5700 Sixth Ave
Altoona, PA 16602 Altoona, PA 16602 Altoona, PA 16602
Name: Stephanie Uoliveira
Name: Joseph S Sheetz
Name: Steven PAugustine
7ille: Vice 1resident
Title: President
Title: Assistant Secrelary
Address:
Address:
Address.
5700 Sixth Ave
5700 Sixth Ave
5700 Sixth Ave
Altoona, PA 16602
Altoona, PA 16602
Altoona, PA 16602
CERTIFICATION OF ANNUAL REPORT MUST BE COMPLETED BY ALL BUSINESS CORPORATIONS
Thomas P Luciano
FORM MAST BF SIGNED BY AN OFFICER OF THE CORPORATION
Thomas P Luciano
2/27/2015
DATE
Vice President
TYPE OR PRIMP' NAME TYPE OR PRINT TITLE
ANNUAL REPORT FEE: E-Paid MAIL TO: Secretary of State • Corporations Division • Post Office Box 29525 • Raleigh, NC 27626-0525

PRINCIPAL OFFICERS: (Continued)
Name: Gary Zimmerman
Title: Assistant Vice President
Address:
5700 Sixth Ave
Altoona, PA 16602
Name: Travis T Sheetz
Title: Vice President
Address:
5700 Sixth Ave
Altoona, PA 16602
Name: David P Hazelet
Title: Assistant Secretary
Address:
5700 Sixth Ave
Altoona, PA 16602
Name: Thomas P Luciano
Title: Vice President
Address:
5700 Sixth Ave
Altoona, PA 16602
Name: Michael A Lacesa
Title: Assistant Secretary
Address:
5700 Sixth Ave
Altoona, PA 16602

AGREEMENT OF SALE
T41S AGREEMENT OF SALE (this "Agreement") is hereby entered into this
day of V (_'-� J> , 2014, (the 'Effective Date", which is the date this Agreement is
signed by the last of the parties hereto) by and between:
BILLY R. MOOSE, with an address of 224 E. Lackey Farm Road, Stony Point, NC
28678 (the "Seller")
and
PTM, L.P., a Delaware limited partnership, or its assigns, having a place of business at
5700 Sixth Avenue, Altoona, Pennsylvania 16602 (the 'Buyer").
RECITALS
A. Seller is the fee owner of a 4.56f acre parcel of land located at the southeast
comer of Salisbury Highway and North Barkley Road; City of Statesville, Iredell County, North
Carolina, being Iredell County parcel number 4743998676.000. Seller having acquired title
thereto by virtue of Deed recorded with the Iredell County Register of Deeds Office at Deed
Book 1028, Page 873, and shown on the Preliminary Site Plan attached hereto as Exhibit "A"
(hereinafter referred to as the "Property").
B. Buyer intends to develop the Property ("Buyer's Project") for a Sheetz
Convenience Store open 24 hours per day, seven days a week with the retail sale of gasoline/auto
diesel, diesel islands, limited indoor and outdoor seating, red back lit canopies, a car wash, and
drive thru (`Buyer's Intended Uses").
C. Seller desires to sell the Property, together with all improvements and fixtures
thereon and all rights, including all mineral, oil, gas rights, privileges, easements, benefits and
agreements appurtenant thereto and Buyer desires to purchase the Property in accordance with
and subject to the terms and conditions hereinafter set forth.
NOW, THEREFORE, in consideration of the mutual promises herein contained, and for
other good .and valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, Buyer agrees to buy and Seller agrees to sell the Property upon the following
terms and conditions:
1.0 Incorporation. The above recitals are hereby incorporated herein by reference as
if more fully set forth herein,

15.6 Other Documents. Buyer and Seller each agree to execute and deliver to
the other party such additional documents as may be reasonably required or necessary for the
consummation of the transaction contemplated by this Agreement.
15.7 Waiver. Failure by Buyer or Seller to insist upon or enforce any of its
rights hereto shall not constitute a waiver thereof.
15.8 Confidentiality. The terms hereof shall be kept confidential by the parties,
except as may be required for the performance of Buyer's due diligence or the filing of any plans
for purpose of development approvals. Either party shall not record this Agreement.
15.9 Headings. The headings of the various paragraphs in this Agreement have
been inserted only for the purpose of convenience and shall not be deemed in any manner to
modify, explain, qualify or restrict any of the provisions of this Agreement,
15.10 Counterparts. This Agreement of Sale maybe executed by the parties in
any number of identical counterparts, all of which shall constitute one agreement.
IN WITNESS WHEREOF, intending to be legally bound hereby, the parties hereto
have set their hands and seals to this Agreement of Sale day and year first above written.
Witness/Attest:
Witness/Attest:
SELLER:
By: 'e,& e 4em-r—�
Billy It. Moose
BUYER:
PTM, L.P., a Delaware limited partnership, by and
through PIE, LLC, Delaware limited liability
company, its gener tner
By:
Joseph S. Sheetz
Vice President

P6 'EI PLANY

Permit Number:
(to be provided by DWQ)
Drainage Area Number:
Sand Filter Operation and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a log in a
known set location. Any deficient BMP elements noted in the inspection will be correct paired or
replaced immediately. These deficiencies can affect the integrity of structures, safety of on
blic, and
the removal efficiency of the BMP.
i
O
Important maintenance procedures: o0,
- The drainage area will be carefully managed to reduce the sediment dt- s&nd fi
- The sedimentation chamber or forebay will be cleaned out whenever s�l ' t de!* e
six inches. � s
- Once a year, sand media will be skimmed.
- The sand filter media will be replaced whenever it fails to function proper; after maintenance.
m
The sand filter will be inspected quarterly and within 24 hours after every storm event greater than
1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance will be kept in
a known set location and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired
immediately.
BMP.'elementr F, ;"
'Potential roblem . ,' ° ' `;
How I,will rethediate.the;problem ., :
Entire BMP
Trash/debris is present.
Remove the trash/debris.
Adjacent pavement (if
Sediment is present on the
Sweep or vacuum the sediment as soon as
applicable)
pavement surface.
possible.
Perimeter of sand filter
Areas of bare soil and/or erosive
Regrade the soil if necessary to remove the
gullies have formed.
gully, and then plant a ground cover and
water until it is established. Provide time
and a one-time fertilizer application.
Vegetation is too short or too long.
Maintain vegetation at an appropriate
height.
Flow diversion structure
The structure is clogged.
Unclog the conveyance and dispose of any
sediment offsite.
The structure is damaged.
Make any necessary repairs or replace if
damage is too large for repair.
Forebay or pretreatment area
Sediment has accumulated to a
Search for the source of the sediment and
depth of greater than six inches.
remedy the problem if possible. Remove
the sediment and stabilize or dispose of it
in a location where it will not cause
impacts to streams or the BMP.
Erosion has occurred.
Provide additional erosion protection such
as reinforced turf matting or riprap if
needed to prevent future erosion
problems.
Weeds are present.
Remove the weeds, preferably by hand. If
a pesticide is used, wipe it on the plants
rather than spraying.
Form SW401-Sand Filter O&M-Rev.4 2009Sep[17 Page 1 of 3

lovo
i.'/e .a.
4. .fie"a

BMP.element:
Potential problem:�' `i _ "`How
Fivill renieilidie`the roblem
Filter bed and underdrain
Water is ponding on the surface for
Check to see if the collector system is
collection system
more than 24 hours after a storm.
clogged and flush if necessary. If water
still ponds, remove the top few inches of
filter bed media and replace. If water still
ponds, then consult an expert.
Outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of the
sediment offsite.
The outlet device is damaged
Repair or replace the outlet device.
Receiving water
Erosion or other signs of damage
Contact the NC Division of Water Quality
have occurred at the outlet.
401 Oversight Unit at 919-733-1786.
Form SW401-Sand Filter O&M-Rev.4 2009Sept17 Page 2 of 3

Permit Number:
(to be provided by DIVA)
I acknowledge and agree by my signature below that I am responsible for the performance of the
maintenance procedures listed above. I agree to notify DWQ of any problems with the system or prior
to any changes to the system or responsible party.
Project name:Sheetz, Inc., Salisbury Highway, Statesville Highway
BMP drainage area number:
Print name:Steven P. Augustine
Title:ASST. VP/Assistant Secretary
Address:5700 Sixth Avenue
Note: The legally responsible parry should not be a homeowners association unless more than 50% of the lots have been
sold and a resident of the subdivision has been named the president.
I, J�r� lea-1Yb,Yf1�CQ a Notary Public for the State of
An ) O� County of- j\(X 1 f do hereby certify that
��n�15�1 Y1E? personally appeared before me this 1")t1y day of
�rcyher b l ; , and acknowledge the due execution of the forgoing sand filter
maintenance requirements. Witness my hand and official seal,
I SCkoAdK.t.-
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
Jennifer D. Schramke, Notary Public
City of Altoona, Blair County
My Commission Expires April 7, 2019
MEMBER. PENNSYLVANIA ASSOCIATION OF NOTARIES
SEAL
My commission expires
Form SW401-Sand Filter O&M-Rev.4 2009Sept17 Page 3 of 3

�Ir � �I ti�'•u ,r,.:un,:-. ivy`"!

Permit
(to be provided by DWO)
!%%!C MEMO E"R. ENT PERMIT APPLICATION FORM
401 CERTIFICATION APPLICATION FORM
SAND FILTER SUPPLEMENT
This form must be filled out on line, printed and submitted with all of the required information.
Make sure to also fill out and submit the Required Items Checklist (Section III) and the I&M Agreement (Section IV)
Project name
Contact name
Phone number
Date
Drainage area number
SHEETZ, INC. - STATESVILLE, NC
2015
1 0 • o a' a t{ >..��"-4 �»r t,+'c'&• :; .'�+���:�: k'�d .4: u-. :,.� ,:s..E. ..�.$�, t.;-�.::
Site Clraracteristics
Drainage area (AD)
44,431.00 ft2 OK
Impervious area
32,234.00 ftz
% Impervious (IA)
72.5% %
Design rainfall depth (Ro)
1.00 in
Peak Flow Calculations
'
1-yr, 24-hr runoff depth
1.63 in
1-yr, 24-hr intensity
0.18 in/hr
Pre -development 1-yr, 24-hr runoff
3.21 ft3/sec
Post -development 1-yr, 24-hr runoff
3.08 it3/sec
Pre/Post 1-yr, 24-hr peak control
-0.13 113/sec
Storage Volume
Design volume (WQV)
2,601.00 h3
Adjusted water quality volume (WQVAd;)
1,950.75 ft' OK
Volume contained in the sedimentation basin and on top of the sand filter
2,903.00 ft3
Top of sand f lter/grate elevation
893 It amsl
Weir elevation (between chambers)
895 ft amsl
Maximum head on the sedimentation basin and sand filter (hMWFlller)
2.00 It OK
Average head on the sedimentation basin and sand filter (hA)
1.00 ft OK
Runoff Coefficient (Rv)
0.70 (unitless)
Type of Sand Filter
Open sand filter?
SHWT elevation
Bottom of the sand filter elevation
Clearance (ds,.,w.r)
Closed/pre-cast sand filter?
SHWT elevation
Bottom of the sand filter elevation
Clearance (dsF )
If this is a closed, underground closed sand filter: The clearance between
the surface of the sand filter and the bottom of the roof of the underground
structure (dsp.)
Y YorN
888.00 ft amsl
891.50 ft amsl
3.50
N YorN
ft amsl
It amsl
iWO �9EAL -=f-;
36627
F P•
i •:�GIN6i:..p)���
�!/l11111111��
Form SW401-Sand Filter-Rev.5 2009Septl7 Parts I and 11. Project Design Summary, Page 1 of 2

,,�..O .i
3?25a �•
'�l;turn;ytt

Permit
(to be provided by DWQ)
Sedimentation Basin
Surface area of sedimentation basin (As)
Sedimentation basin/chamber depth
Sand Filter
Surface area of sand filter (AF)
Top of sand media filler bed elevation
Bottom of sand media filter bed/drain elevation
Depth of the sand media filter bed (dF)
Coefficient of permeability for the sand filter (k)
Outlet diameter
Outlet discharge/flowrale
Time to drain the sand filler (t)
Time to drain the sand filter (t)
Additional Information
Does volume in excess of the design volume bypass the sand filter?
Is an off-line flow -splitting device used?
If draining to SA waters: Does volume in excess of the design volume flow
evenly distributed through a veqetated filter?
What is the length of the vegetated filter?
Does the design use a level spreader to evenly distribute flow?
Is the BMP located at least 30ft from surface waters (50ft if SA waters)?
If not a closed bottom, is BMP located at least 10011 from water supply wells?
Are the vegetated side slopes equal to or less than 3:1
Is the BMP located in a recorded drainage easement with a recorded access
easement to a public Right of Way (ROW)?
What is the width of the sedimentation chamber/forebay (Wsee)?
What is the depth of sand over the ouflet pipe (dpipe)?
272.00 ft2 OK. Meets minimum, but may need to be increased to
2.00 ft
330.00 ft' OK. Meets minimum, but may need to be increased to
893.00 ft artist
891.50 ft amsl
1.50 ft
3.50 (ftday)
6.00 in
0.04 ft3/sec
40.00 hours OK. Submit drainage calculations.
1.67 days
Y
YorN
OK
Y
YorN
OK
YorN
It
YorN
Y
YorN
OK
Y
YorN
OK
Y
Y or N
OK
Y
Y or N
OK
15A0 ft
OK
1.50 It
OK
Form SW401-Sand Filter-Rev.5 200gSeptW Parts I and II. Project Design Summary, Page 2 of 2

Permit No.
(to be provided by DWQ)
Please indicate the page or plan sheet numbers where the supporting documentation can be found. An incomplete submittal
package will result in a request for additional information. This will delay final review and approval of the project. Initial
in the space provided to indicate the following design requirements have been met. If the applicant has designated an agent,
the agent may initial below. If a requirement has not been met, attach justification.
Initials Pagel Plan
Sheet No.
M.E. APPENDIX "A' 1. Plans (1" - 50' or larger) of the entire site with labeled drainage area boundaries
- System dimensions (length, width, and depth) for both the sedimentation chamber and the filter
chamber,
- Maintenance access,
- Flow splitting device,
- Proposed drainage easement and public right of way (ROW),
- Design at ultimate build -out,
- Off -site drainage (if applicable), and
- Rnnndnrioe of Hreinono comment
M.E. SHEET 23 2. Plan details (1" = 30' or larger) for the sand filter showing:
- System dimensions (length, width, and depth) for both the sedimentation chamber and the filter
chamber,
- Maintenance access,
- Flow splitting device,
- Vegetative filter strip dimensions and slope (if SA waters),
- Proposed drainage easement and public right of way (ROW),
- Design at ultimate build -out,
- Off -site drainage (if applicable), and
- Boundaries of drainage easement.
M.E. PAGE 5 3. Section view of the sand filter (1" = 20' or larger) showing:
- Depth(s) of the sedimentation chamber and sand filter chamber,
- Depth of sand filter media,
- Connection between the sedimentation chamber and the sand filter chamber and weir elevation,
- SHWT elevation,
- Outlet pipe, and
- Clearance from the surface of the sand filter to the bottom of the roof of the underground structure (if
annlirahle).
M.E. ATTACHED 4. A soils report that is based upon an actual field investigation, soil borings, and infiltration tests. The
results of the soils report must be verified in the field by DWQ, by completing & submitting the soils
investigation request form. County soil maps are not an acceptable source of soils information.
M.E. PAGE2 5. Supporting calculations (including drainage calculations)
M.E. ATTACHED 6. Signed and notarized operation and maintenance (0&M) agreement
M.E. N/A 7. A copy of the deed restrictions (if required).
Form SW401-Sand Filter-Rev.5 2009Sept17 Part III, Page 1 of 1

Figure 1: Open Sand Filter
Sedimentation
Chnutber
(or Forebay)
FI ow
—111'.
Smicl Filter
Chamber
A
r 1
Outlet Pipe
I I.,...I (IF ' (IF
2* ti 12t 11 I (IsHwr
in -Situ Soil: SeasonablNi Mali WaterTnble
..................................
Sed
Figure 2: Closed Sand Filter
Cover Grates
Weir low; .,
`.
-
Overlandr flow's:
` Concrete Chamber
��, t•
° dSpace, hMax Filter
Ito
dpipe d
SHVIT
Sedimentation Chamber
(Deposition of Heavy sediments,
WSed
Sand Filter Chamber
(Filtration of solids)