SW3191201_Application_20191203

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
GL QZ % 95'0
100Z D (
Applicable Rules: ❑ Coastal SW -1995 ❑ Coastal SW - 2008 ❑ Ph II - Post Construction
(select all that apply) ❑ Non -Coastal SW- HQW/ORW Waters ❑ Universal Stormwater Management Plan
❑ Other WQ Mgmt Plan:
State of North Carolina
Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources _
STORMWATER MANAGEMENT PERMIT APPLICATION FORM
This form may be photocopied for use as an original DEC 0 3 2019
I. GENERAL INFORMATION DENWR-LAND QUALITY
1. Project Name (subdivision, facility, or establishment name - should be consistent with prolecf i aTme oi�Nr'
specifications, letters, operation and maintenance agreements, etc.):
Circle K Denver (Unity Church Rd)
2. Location of Project (street address):
NE corner NC-16 Business and Unity Church Rd (Propertyis being subdivided; address will be provided
when available.
City:Catawba Springs County:Lincoln Zip:28037
3. Directions to project (from nearest major intersection):
NC-16 to ORtimist Club Road. East on Optimist Club Road to Triangle Circle. North on Triangle Circle to
NC-16 Busines. Site is located on NE corner of NC-16 Business and Unity Church Road.
4. Latitude:350 28' 46" N Longitude:80° 59' 35" W of the main entrance to the project.
II. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tRenewals 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* [ICompleted* *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
DEMLR 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):
❑CAMA Major ❑Sedimentation/Erosion Control: _
❑NPDES Industrial Stormwater ❑404/401 Permit: Proposed Impacts
ac of Disturbed Area
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:Sedimentation/Erosion Control permit is being anylied for separately
through regional Mooresville NC DEO office.
5. Is the project located within 5 miles of a public airport? ®No ❑Yes
If yes, see S.L. 2012-200, Part VI: httn:////12ortal.ncdenr.orglweb/Ir/rules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Page I of 6

III. CONTACT INFORMATION
a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the project):
Applicant/Organization: Mark Ostoits/ Circle K Stores Inc.
Signing Official & Title:Vice President
b. Contact information for person listed in item 1a above:
Street Address:2550 W. Tyyola Road, Suite 200
City:Charlotte State:NC Zip:28217
Mailing Address (if applicable):Same as above
City: State: Zip:
Phone: ( ) Fax: ( 1
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: Statesville Road Land Company
Signing Official & Title:lames S. King
b. Contact information for person listed in item 2a above:
Street Address:8430 Double Ea¢le Gate Wa
City:Charlotte State:NC Zip:28217
Mailing Address (if applicable):Same as above
City: State: Zip:
Phone: (_ -) Fax: f )
3. a. (Optional) Print the name and title of another contact such as the project's construction supervisor or other
person who can answer questions about the project:
Other Contact Person/Organization:Haytham Kasem
Signing Official & Title:Construction Manager
b. Contact information for person listed in item 3a above:
Mailing Address:2550 W. Tyvola Road, Suite 200
City:Charlotte State:NC Zip:28217
Phone: (704 ) 776-6444 Fax: ( )
Email:[e-mail]
4. Local jurisdiction for building permits: Lincoln County
Point of Contact:Andrew Bryant Phone #: (704 ) 736-8440
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. PROJECT INFORMATION
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
Runoff from all impervious areas will be directed to either a bioretention area or a sand filter. Both systems
are designed to attenuate the 10-,year peak flow.
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 II - Post Construction
3. Stormwater runoff from this project drains to the Catawba River basin.
4. Total Property Area: 3.65 acres
5. Total Coastal Wetlands Area: 0 acres
6. Total Surface Water Area: 0 acres
7. Total Property Area (4) - Total Coastal Wetlands Area (5) - Total Surface Water Area (6) = Total Project
Area+:3.65 acres
+ Total project area shall be calculated to exclude the following: the normal pool of im ounded structures, the area
between the banks of streams and rivers, the area below the Normal Hi h Water (NM line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHi line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -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 = 47.0 %
9. How many drainage areas does the project have?4 (For high density, count 1 for each proposed engineered
stormwater 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
Drainage Area A
Drainage Area B
Drainage Area C
Drainage Area D
Receiving Stream Name
Lake Norman
Lake Norman
Lake Norman
Lake Norman
Stream Class *
WS-IV
WS-IV
WS-IV
WS-IV
Stream Index Number
Total Drainage Area (sf)
86244
8898
39892
24214
On -site Drainage Area (so
72159
0
5707
24214
Off -site Drainage Area (so
14085
8898
34185
0
Proposed Impervious Area** (so
59726
0
278
15408
% Impervious Area** total
69.3
0
0.7
63.6
Impervious** Surface Area
Drainage Area A
Drainage Area B
Drainage Area C
Drainage Area D
On -site Buildings/ Lots (so
6676
0
0
0
On -site Streets (sf)
6779
0
0
0
On -site Parkin (sf)
28738
0
0
14001
On -site Sidewalks (s
2706
0
0
1407
Other on -site (so
742
0
0
0
Future (so
0
0
0
0
Off -site (sf)
14085
0
0
0
Existing BUA*** (sf)
0
1 0
0
0
Total (so:
59726 1
0
0
15408
* Stream Class and Index Number can be determined at: ht!V.Y-&ortal.ncdenr-org1tveb/wq[ps/csu/classifications
** Im envious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

'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. Drainage study
includes new access drive (see attached Post Drainage Area Exhibit). Runoff from new acces drive
is routed through sand filter in Drainage Area A.
Proiects in Union County: Contact DEMLR Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that may be subject to lore stringent stormwater 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 BUT specified for this project. The latest versions of the forms can be downloaded
from http://12ortal.ncdenr.org/web/wg/ws/su/bmg-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
http://12ortal.ncdenr.org/web/3yq/ws/su/statesw/forms docs. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at h!W://12ortal.ncdenr.org/web/­3yg/ws/su/ma]2s.)
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 initialed in blue ink. Download the latest versions
for each submitted application package from http://portal.ncdenr.org/web/wq/ws/su/statesw/forms dots.
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 _ t�
h!W://www.envheIR.oriz/Rages/"onestopexvress.htnd for information on the Express program
and the associated fees. Contact the appropri to 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/management for
6. A USGS map identifying the site location. If the receiving stream is reported as class SA or the _4L-2
receiving stream drains to class SA waters within 1/2 mile of the site boundary, include the 1/2
mile radius on the map.
7. Sealed, signed and dated calculations (one copy). V --0
8. Two sets of plans folded to 8.5" x 14" (sealed signed, & dated), including: ✓w
a. Development/Project name.
b. Engineer and firm.
c. Location map with named streets and NCSR numbers.
d. Legend.
e. North arrow.
f. 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.
in. 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.
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

o. Drainage areas delineated (included in the main set of plans, not as a separate document).
p. Vegetated buffers (where required).
9. 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"x11" 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 DEMLR to verify the SHWF prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 2630 Page No: 357 JV0
11. For corporations and limited liability corporations (LLC): Provide documentation from the NC ecO
Secretary of State or other official documentation, which supports the titles and positions held
by the persons listed in Contact Information, item 1a, 2a, and/or 3a per 15A NCAC 21-1.1003(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.
http: / /www.secretaiy.state.nc.us/Corporations/CSearch.asl2x
VII. 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/lr/state-
stormwater-forms docs. 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 ovenants 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 DEMLR, 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:Kai Burk
Consulting Firm: Bowman Consulting
Mailing Address:950 North Point Parkway, Suite 200
City:Alpharetta State:GA Zip:30004
Phone: (678 ) 374-6687 Fax:
Email:[e-mail]
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) fames S. King , 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 1a) Mark Ostoits with (print or type name of organization listed in
Contact Information, item 1a) Circle K Stores 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 Oct. 31, 2013 Page 5 of 6

ku
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 DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR 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 includirIg the assessmentpf civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signaturi1e:' q Date:
I, ya t2CtI / r eQ1 Kqa a Notary Public for the State of Ndr4A CAP-0/1 HA , Countyof
MeC do hereby certify that 'eS 14J K personally appeared
before me this day of NOVeW i-e i' 20 and acknowled�dueon of the application for
a stormwater permit. Witness my hand and official seal,
MATTHEW THEDINGA
Notary Public
Mecklenburg Co., North Carolina
My Commission Expires Sept. 4, 2023
X. APPLICANTS CERTIFICATION
SEAL
My commission expires 0 26'23
I, (print or type name of person listed in Contact Information, item 1a) Mark Ostoits
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, and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 21-1.1000 and any other applicable state stormwater requirements.
Signature: /," Dater%% 14
I, �&J V I GI qon a Notary Public for the State of County of
MCClifeAbLA rA , do hereby certify that Mb K personally appeared
before me this 8 day of 03tIC0191 X andacknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, 1 c llAlag�
KARIA YON
NOTARY PUBLIC
med*n" County
North Cwalm
� C�ortunuf�ion E�kN
SEAL
My commission expires 0-:�./I V a Ca 2
Form SWU-101 Version Oct. 31, 2013
Page 6 of 6

Stormwater Management Permit Application
Circle K Denver (Unity Church Rd)
Section IV Submittal Reauirements — Narrative for Checklist Items
Item #2 — Provision of Deed Restriction document is not provided in this submission. This project is
providing stormwater control for one commercial parcel and a corresponding access road. It is not
providing stormwater control for any adjacent or nearby parcels.

North Carolina Secretary of State Search Results
Page 1 of 2
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Business Corporation
Legal Name
Circle K Stores Inc.
Prev Legal Name
Circle K Convenience Stores, Inc.
Prev Legal Name
The Circle K Corporation
Information
Sosld: 0176043
Status: Current -Active
Annual Report Status: Current
Citizenship: Foreign
Date Formed: 10/25/1985
Fiscal Month: April
State of Incorporation:
TX
Registered Agent: Corporation Service Company
Addresses
Mailing
1130 West Warner Road, Building B
Tempe, AZ 85284-2816
Reg Mailing
2626 Glenwood Avenue, Suite 550
Raleigh, NC 27608-1370
Officers
Principal Office
1130 West Warner Road, Building B
Tempe, AZ 85284-2816
Reg Office
2626 Glenwood Avenue, Suite 550
Raleigh, NC 27608-1370
Assistant Secretary
Assistant Secretary
Senior Vice President
Vice President
Christine Anagnostou
Kimberly Andrews
Brian Bednarz
Rodney Blanton
4204 Industriel
5500 S Quebec St. Suite 100
25 W. Cedar Street, Suite 100
2440 Whitehall Park Dr
Laval XX H7LOE3
Greenwood Village CO 80111
Pensacola FL 35202
Charlotte NC 28273
Assistant Secretary
Senior Vice President
President
Aaron Brooks
Kathy Cunnington
Kathy Cunnington
305 Gregson Dr.
1130 West Warner Road Building B 1130 West Warner Road Building B
Cary NC 27511
Tempe AZ 85284
Tempe AZ 85284
https://www.sosnc.gov/online_services/search/Business_Registration_Results 12/4/2019

North Carolina Secretary of State Search Results
Page 2 of 2
Treasurer
Kathy Cunnington
1130 West Warner Road Building B
Tempe AZ 85284
Assistant Secretary
Mike Foster
2440 Whitehall Park Drive, Suite 800
Charlotte NC 28273
Assistant Secretary
Kim Kwiatkowski
1130 West Warner Road, Building B
Tempe AZ 85284
Secretary
KATHY C. CUNNINGTON
1130 WEST WARNER ROAD
TEMPE AZ 85284
Assistant Secretary
Edward Giunta
12911 N Telecom Parkway
Tampa FL 33637
Vice President
Luc Langevin
12911 N. Telecom Parkway
Tampa FL 33637
Executive Officer
Darrell Davis
12911 N. Telecom Parkway
Tampa FL 33637
Assistant Secretary
Randy Horne
25 W Cedar Street Suite 100
Pensacola FL 32502
Assistant Secretary
John Little
305 Gregson Drive
Cary NC 27511
Assistant Secretary
Sarah Longwell
495 E Rincon, suite 150
Corona CA 92879
Vice President Executive Officer Vice President
Matt Mccure Alex Miller David G Morgan
2440 Whitehall Park Drive Suite 800 1130 West Warner Road Building B 12911 N Telecom Parkway
Charlotte NC 28273 Tempe AZ 85284 Tampa FL 33637
Vice President
Assistant Secretary
Vice President
Vice President
Mark Ostoits
Patrick Panzarella
Trey Powell
Meredith Will Rice , Jr.
2550 West Tyvola road Suite 200
19500 Bulverde Road
25W. Cedar Street, Suite 100
1100 Situs Court Suite 100
Charlotte NC 28217
San Antonio TX 78259
Pensacola FL 35202
Raleigh NC 27606
Vice President
Paul Rodriguez
1130 West Warner Road, Building B
Tempe AZ 85284
Vice President
Tim Tourek
255 E.Rincon Suite 100
Corona CA 92879
Stock
Class: COMMON
Shares: 12000000
Par Value 1
Vice President
Mark Tate
5500 S Quebec St. Suite 100
Greenwood Village CO 80111
Senior Vice President
Dennis Tewell
1130 West Warner Road, Building B
Tempe AZ 85284
https://www.sosnc.gov/online_services/search/Business_Registration_Results 12/4/2019