SW3191201_Supplemental Info Review_12/5/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/5/2019 9:05:04 AM (Supplemental Submittal)
Submit by Strickland, Shane 12/5/2019 10:37:46 AM (Supplemental Info Submittal)
• The task was assigned to Strickland, Shane 12/5/2019 9:05 AM

Submittal Dated: 12/5/2019
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Existing Project Information:
Rease suDDly the Derrrit nunber for this Drolect.
D# * Perrrit N irrber
SW3191201
Examples: SWxxxxxxx, NC Gxxxxxx, or NCSxxxxxx
Facility Name:* Circle K Denver (Unity Church Rd)
County: Lincoln
Name: Bridgette Ganter
Vft is subrritting the inforr ation?
Email Address:* [e-mail]
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach docurrent
Circle K Denver (Unity Church Rd) Civil Plans_11-
48.58M6
27-19.pdf
Circle K Denver Stormwater Application_signed.pdf
454.65KB
Deeds.pdf
1.08MB
Denver Unity Church Rd Circle K Drainage
3.67M6
Report.pdf
North Carolina Secretary of State - Circle K Stores
157.05K6
Inc.pdf
North Carolina Secretary of State Search -
62.2K6
Statesville Road Land Company.pdf
O&M EZ 0714141.1 (2).pdf
1.61 MB
Stormwater Management Narrative.pdf
51.27KB
Supplement Form.pdf
173.05KB
Only pdf files are accepted.
Please alert us to any confidential information contained in the uploaded documents.
Uploads contain r NO
Confidential r YES
Information * NOTE The following infornation cannot be claimed as confidential: the nave and address of any perrrit applicant or
perrrittee, perrrit applications, perrrits, effluent data, information required by WCM application forms provided by
the Director inclusive of all forrrs and attachments [Ref. 40 CFR 122.7(b) and (c)].

Describe the attachments:
Civil Plans
Stormwater Application
Drainage Report
Stormwater Narrative
Supplement Form
O&M Agreement
Deeds
Proof of Company Affiliation (Secretary of State records)
* V By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
• 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)
• 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');
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
• I intend to electronically sign and submit the Supplemental Information form."
Full Name:* Bridgette Ganter
Signature:
Date Submitted: 12/5/2019

Initial Review
Updated ID#: IWORfANT. RE\/1RAE 2SH0LLDVMFY and revise here if necessary.
SW3191201
Who needs a W Central Office
copy?* r Regional Office
Central Office Reviewer:*
Corey Anen - eads\scanen
Select Reviewing Office*
Mooresville Regional Office — 704-663-1699
Select RO Reviewer:*
[e-mail]