SW6130203_Application Form_20240116 (2)

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Date Received Fee Paid Permit Number
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER:
PERMIT RENEWAL APPLICATION FORM
in accordance with 15A NCAC 2H.1045(3), the current permit holder shall renew their high density permit 180 days
prior to its expiration. Renewed permits are valid for a period of 8 years per Session Law 2011-398(SB 781)
Section 60.(c). This application form is for permit renewals only.
A. PROJECT INFORMATION
1. State Stormwater Permit Number: SW6130203
2. Project name: Family Dollar Store #705283
3. Project street address: (i)'1¶5 f0 v+'ra 1(U Lakc I s UCHd
City: ra4jr4 County: Hain(f ZIP : 21332
4. What, if any, changes have been made to the project as permitted? (1611e
If the project has changed from the original approved plans, please complete SWU-101 for a Major
Modification or Minor Modification Application form available at: https.//deq.nc.gov/about/divisions/energy-
mineral-land-resources/energy-mineral-land-rules/stormwater-program/post-construction.
B. PERMITTEE INFORMATION
If changes to the permittee or project name have been made, please complete either the Permit Update form
or the Permit Transfer form available at: https://deg.nc.gov/about/divisions/energy-mineral-land-
feSources/energy-mineral-land-rules/stormwater-program/post-construction. State Stormwater Permits do not
automatically transfer with the sale of the property.
1. Current Permit Holder's Company Name/Organization: fl J( De ve i u O Yl e, �
2. Signing Official's Name: 61/1 r• E . Fyan k t ti''E1 v t'ci ii r
3. Signing Official's Title: pre 5‘Cte -t
4. Mailing Address: �j 5-0 U(-1 vl r r D Y')'V t
City: -Fr.,ye heAi i' 1 I( J State: M.. ZIP : z 303
5. Street Address: O (.!_)% 9' ec V i ►'i e
City: - -G\. .? Ft-{ v, tie State: ,,tic' ZIP : f,r
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6. Phone: ( tV) ?Y_$i;ck() Email: t �s rat
Stormwater Permit Renewal Form Page 1 of 3 May 11,2018

C. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non-Coastal HQW/ORW). Only applications packages that
include all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the application package:
1. A permit application processing fee of$505.00 payable to NCDEQ.
2. One original signed hard copy and one electronic copy of this completed form. The signing official
named on this application to represent the current permittee must meet one of the following:
a. Corporation—a principle executive officer of at least the level of vice-president;
b. Limited Liability Company (LLC)—a manager or company official as those terms are defined
in G.S. 57D"North Carolina Limited Liability Company Act;"
c. Public Entity—a principal executive officer, ranking official, or other duly authorized employee;
d. Partnership or limited partnership—the general partner;
e. Sole proprietor; or
f. Letter of authorization signed by one of the signatories noted in a—e above authorizing the
signature of another entity.
nki 3. One hard copy and one electronic copy of recorded documents required by the original permit that
have not yet been received by DEMLR, including: deed restrictions, protective covenants,
condominium/planned community declaration and easements. If the project has been built, include
documentation that the maximum BUA per lot or maximum total BUA has not been exceeded. If
the project has not been built, include a signed agreement that the final recorded deed restrictions
and protective covenants will be submitted at a later date.
✓ 4. ,,..Agreements, Please select one:
O have a copy of the current recorded O&M Agreement for all SCMs, and I will continue to
keep this on file with the permit; or
❑ I do not have a copy of the current recorded O&M Agreement for all SCMs and am
requesting a copy be sent to me. I agree to keep this on file with the permit.
✓ 5. DDes2ner Certifications, Please select one:
L� A copy of the certification(s) confirming that the project was built in accordance with the
� approved plans have been previously provided to the Division; or
L--t' A copy of the certification(s) confirming that the project was built in accordance with the
approved plans are enclosed; or
❑ The project has not yet been built.
6. [IF APPLICABLE] If the project has been built, one original hard copy and one electronic copy of a
signed, sealed, and dated letter from a licensed professional stating that the SCMs have been
inspected, and that they have been built and maintained in accordance with the permit.
[IF APPLICABLE] When the permittee is a corporation or a limited liability corporation (LLC):
Provide one hard copy and one electronic copy of documentation from the NC Secretary of State,
or other official documentation, which supports the titles and positions held by the persons listed in
Section C.2 per 15A NCAC 2H. 1043(3)(b).
t-a tps iwww sosnc.00v/online services/search/by title/ Business Registration
Stormwater Permit Renewal Application Form Page 2 of 3 May 11,2018

D. PERMITTEE'S CERTIFICATION
I, tr • fra0 k £AJ O vfr lli , the person legally responsible for the permit, certify that I have
a copy of the Permit and O&M Agreement on site (or I will obtain a copy and it will be kept on site), that I am
responsible for the performance of the maintenance procedures, and the site has been and will be maintained
according to the O&M Agreement and approved plans. I agree to notify DEMLR of any problems with the SCMs
or built-upon area and to submit the proper forms to modify or transfer the permit prior to any changes to the
project, SCMs, or ownership. All information provided on this permit renewal application is, to the best of my
knowledge, correct and complet
Signature: .J _,e( Date: — -27-2.3
NOTARIZATION:
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I, 0/6�'1 E ( 1 C,ttoc�>L , a Notary Public for the State of
1(j\ NO iA)A- , County of arl �V> ( , do herebycertify
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that e . n(,4A�V Wes-_�LL--- personally appeared before me
thiOl eMCCEmil ,„ 9i day of a filet , 20 a 3 , and acknowledge the due
;.t' icution of thO4f�of�,oing instrument. Witness my hand and official seal,
= NOTARY •
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My commission expires 71?2/.1-40
Storrnwater Permit Renewal Application Form Page 3 of 3 May 11,2018