SW5111001_CURRENT PERMIT_20111130

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW
DOC TYPE
CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
DOC DATE]/�/�
YYYYMM DD

NCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Mr. Ernie Rhymer
Quality Oil Company, LLC
P.O. Box 2736
Winston-Salem, NC 27102-2736
Division of Water Quality
Coleen H. Sullins
Director
November 30, 2011
Subject: Stormwater Permit No. SW5111001
Angier Perfect Gas House
High Density Commercial Sand Filter Project
Wake County
Dear Mr. Rhymer:
Dee Freeman
Secretary
The Stormwater Permitting Unit received a complete Stormwater Management Permit Application for
Angier Perfect Gas House on November 23, 2011. 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.1000 and Session Law 2006-246. We are forwarding Permit No. SW5111001, dated November
30, 2011, for the construction, operation and maintenance of the subject project and the stormwater BMPs.
This permit shall be effective from the date of issuance until November 29, 2021, and shall be subject to
the conditions and limitations as specified therein, and does not supersede any other agency permit that
may be required. Please pay special attention to the conditions listed in this permit regarding the Operation
and Maintenance of the BMP(s), recordation of deed restrictions, procedures for changes of ownership,
transferring the permit, and renewing the permit. Failure to establish an adequate system for operation and
maintenance of the stormwater management system, to record deed restrictions, to follow the procedures
for transfer of the permit, or to renew the permit, will result in future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing upon written request within thirty (30) days following receipt of this permit.
This request must be in the form of a written petition, conforming to Chapter 1506 of the North Carolina
General Statutes, and filed with the Office of Administrative Hearings, P.O. Drawer 27447, Raleigh, NC
27611-7447. Unless such demands are made this permit shall be final and binding.
This project will be kept on file at the Raleigh Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Robert Patterson at [phone]; or
[e-mail].
Sincerely,
11
for Coleen H. Sullins
Wetlands and Stormwater Branch One
1617 Mail Service Center, Raleigh, North Carolina 27699-1517 NorthCarolina
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] L FAX [phone] Customer Service: 1-877-623-6748 Naturally
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer

Mr. Ernie Rhymer
SW5111001 — Angier Perfect Gas House
November 30, 2011
CC' SW5111001 File
Ashton R. Smith, PE — ms consultants, inc.
ec: Danny Smith — Raleigh Regional Office
Page 2 of 2

State Stormwater Permit
Permit No. SW5111001
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of
North Carolina as amended, and other applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Quality Oil Company, LLC
Angier Perfect Gas House
3585 S. NC 55 Hwy., Willow Spring, Wake County
FOR THE
construction, operation and maintenance of a sand filter in compliance with the
provisions of Session Law 2006-246 and 15A NCAC 2H .1000 (hereafter referred to
as the "storm water rules') and the approved stormwater management plans and
specifications and other supporting data as attached and on file with and approved
by the Division of Water Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until November 29, 2021,
and shall be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
This permit is effective only with respect to the nature and volume of
stormwater described in the application and other supporting data.
2. This stormwater system has been approved for the management of
stormwater runoff as described in Section 1.7 of this permit. The stormwater
control has been designed to handle the runoff from 28,392 square feet of
impervious area.
3. The tract will be limited to the amount of new built -upon area as indicated in
Section 1.7 of this permit, and per the application documents and as shown on
the approved plans.
4. 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.
5. The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
6. The built -upon areas associated with this project shall be located at least 30
feet landward of all perennial and intermittent surface waters.
Page 1of6

State Stormwater Permit
Permit No. SW5111001
7. The following design criteria have been provided in the sand filter and must
be maintained at design condition:
a. Drainage Area, acres:
Onsite, ftz:
Offsite, ftz:
b. Total Impervious Surfaces, ftz:
Onsite, ftz:
Offsite, ftz:
C. Design Storm, inches:
d. Sediment Chamber Bottom Elev., fmsl
d. Top of Sand Elevation, fmsl:
e. Seasonal High Water Table, fmsl:
f. Sand Depth, feet:
h. Bottom of Sand Elevation, fmsl:
i. Sediment Chamber SA, ftz:
i. Sand Chamber SA, ftz:
j. Permitted Storage Volume, ft3:
k. Bypass 1 Storage Elevation, fmsl:
n. Drawdown Time, hours:
o. Underdrain Diameter, inches:
q. Receiving Stream/River Basin:
r. Stream Index Number:
S. Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
0.81
35,184
0
28,392
28,392;
0
1.0
343.7
343.5
342.0
1.5
342.0
3,168
15.33
1,710
345.5
26
4.0
UT to Neills Creek 1 Cape Fear
18-16-(0.7)
"WS-IV"
1. The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
2. During construction, erosion shall be kept to a minimum and any eroded
areas of the system will be repaired immediately.
3. The permittee shall at all time provide the operation and maintenance
necessary to assure the permitted Stormwater system 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.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans.
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.
4. Records of maintenance activities must be kept for each permitted BMP. The
reports will indicate the date, activity, name of person performing the work
and what actions were taken.
5. The permittee shall submit to the Division of Water Quality an annual
summary report of the maintenance and inspection records for each BMP.
The report shall summarize the inspection dates, results of the inspections,
and the maintenance work performed at each inspection.
6. The facilities shall be constructed as shown on the approved plans. This
Page 2of6

State Stormwater Permit
Permit No. SW5111001
permit shall become void unless the facilities are constructed in accordance
with the conditions of this permit, the approved plans and specifications, and
other supporting data.
7. 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 system installed
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.
8. 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.
9. Access to the stormwater facilities shall be maintained via appropriate
recorded easements at all times.
10. 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.
11. The permittee shall submit final site layout and grading plans for any
permitted future areas shown on the approved plans, prior to construction.
12. A copy of the approved plans and specifications shall be maintained on file by
the Permittee for a minimum of ten years from the date of the completion of
construction.
13. 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
I. 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 Division of Water -Quality, accompanied by the supporting
documentation as listed on page 2 of the form. The approval of this request
will be considered on its merits and may or may not be approved.
Page 3of6

State Stormwater Permit
Permit No. SW5111001
2. 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 Division of Water Quality,
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.
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 2H.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 30" day of November, 2011.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
✓zqP vx�'-7'
forColeen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Page 4of6

State Stormwater Permit
Permit No. SW5111001
Angier Perfect Gas House
Stormwater Permit No. SW5111001
Wake County
Designer's Certification
I, , as a duly registered in the State of
North Carolina, having been authorized to observe (❑ periodically 1 ❑ weekly 1
❑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.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
Page 5 of 6

State Stormwater Permit
Permit No. SW5111001 "
Certification Requirements:
1. The drainage area to the system contains approximately the permitted
acreage.
2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
3. All the built -upon area associated with the project is graded such that
the runoff drains to the system.
4. All roof drains are located such that the runoff is directed into the
system.
5. The outlet/bypass structure elevations are per the approved plan.
6. The outlet structure is located per the approved plans.
7. Under drains are located per the approved plans.
8. All slopes are grassed with permanent vegetation, per the vegetation
plan.
9. Vegetated slopes are no steeper than 3:1.
10. The inlets are located per the approved plans and do not cause short-
circuiting of the system.
11. The permitted amounts of surface area and volume have been
provided.
12. Required drawdown devices are correctly sized per the approved plans.
13. All required design depths are provided.
14. All required parts of the system are provided, such as a sediment
chambers, sand chambers, under drains, and outlets.
15. The required system dimensions are provided per the approved plans.
Please submit this Designer's Certification to: Raleigh Regional Office
Surface Water Protection
3800 Barrett Dr.
Raleigh, NC 27609
1.1
Betty Pearson -Town of Angier
Building Inspections
Page 6of6

DWQ USE ONLY
Pate Received
Fee raid
Permit Number
10Z1 `1
1 4.5'DS xt tD-1
li10oi
Applicable uIA: ❑ Coastal SW -1995 ❑ Coastal SW -- 2008 0 Ph II - 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 FORM
This form may be photocopied for use as an original
I. GENERAL INFORMATION
1. Project Name (subdivision, facility, or establishment name - should be consistent with project name on plans,
specifications, letters, operation and maintenance agreements, etc.):
Oualtv Oil Comaanv, LLC Anizier Perfect Gas House
2. Location of Project (street address):
3585 S. NC 55 Hwy, Willow Spring, NC
City: Angier County: Wake Lip:27592
3. Directions to project (from nearest major intersection):
Project site is the NE corner of the intersection of Hwy 55 and Kennebec Rd.(SR 2762)
4. Latitude:35° 32' 13,84" N Longitude:78° 44' 46.67" W of the main entrance to the project.
H. PERMIT INFORMATION:
1. a. Specify whether project is (check one): ®New ❑Modification
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
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):
❑CAMA Major ®Sedimentation/Erosion Control: 2.2 ac of Disturbed Area
❑NPDES Industrial Stormwater 0404/401 Permit: Proposed Impacts
b.lf any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit: The S&EC plan has been submitted _
Tro',.
Form SWU-101 Version 07Jun2010 Page I of

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 project):
Applicant/Organization: Quality Oil Company, LLC
Signing Official & Title:Ernie Rhymer, Senior Vice President
b.Contact information for person listed in item 1a above:
Street Address:1540 Silas Creek Parkway
City: Winston-Salem State:NC Zip:27102
Mailing Address (if applicable):P.O. Box 2736
City: Winston-Salem State:NCZip:27102-2736
Phone: (336 _) 722-3441 Fax: (336 ) 721-9522
Email:[e-mail]
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: Henry Leigh Ballance
Signing Official & Title: Hence Leigh Ballance
b.Contact information for person listed in item 2a above:
Street Address: 2209 Hamrick Drive
City: Raleigh � State: NC Zip: 27613
Mailing Address (if applicable):
City:
Phone: (919 ] 616-7533
Email: bal14246©bellsouth.net
State: Zip:
Fax: ( ]
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: Cray, A. Perry. PE, ms consultants, inc.
Signing Official & Title: Crag A. Perry, Project Manager
b. Contact information for person listed in item 3a above:
Mailing Address: 70 East Business Park,155 US Highway 70 West
City: Garner State: NC Zip: 27529-3942
Form SWU-101 Version 07.iun2010 Page 2 of

Phone: (919 _) 772-5565
Fax: (919 ) 779-2308_
Email:_perry®msconsultants.co_m
4. Local jurisdiction for building permits: Town of An ier
Point of Contact: Bet Pearson
IV. PROJECT INFORMATION
Phone #: (919 ) 639-2071
1. In the space provided below, briefly summarize how the stormwater runoff will be treated.
The first inch of stormwater will be trapped and detained in an underground gravel filter bed. It will then be
filtered at a controlled rate through a sand filter
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 Cape Fear _ River basin.
4. Total Property Area: 1.43 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+:1.43 acres
+ Total project area shall be calculated to exclude the following the normal pool of impounded structures, the area
between the batiks of streants and rivers, the area below the Normal Hi It Water (NNW) lime or Mean High Water
(MHM litre, and coastal wetlands landward from the NHW (or NX lute. The resultant project area is rued to
calculate overall percent built upon area (BLIA). Non -coastal wetlands landward of the NNW (or MHW) titre nuay
be included in file total project area.
8. Project percent of impervious area: (Total Impervious Area [Total Project Area) X 100 = 45
9. How many drainage areas does the project have?1 (For high density, count I for each proposed engineered
stormwater BMP. For low density and other projects, use 1 for ttre 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.
Form SWU-101 Version 07Jun2010 Page 3 of 7

Basin Information
Drainage Area 1
_
Drainage Area _
Drainage Area _
Drainage Area _
Receiving Stream Name
Un-named
tributary to
Neills Creek
Un-named
tributary to
Neills Creek
Stream Class
WS-IV
WS-IV
Stream Index Number *
18-16-(0.7)
18-16-(0.7)
Total Drainage Area (so
35,184
On -site Drainage Area (so
35,184
Off -site Drainage Area (sf)
0
Proposed Impervious Area** (SO
28,392
% Im ervious Area** total
80.7
Impervious— Surface Area
Drainage Area _
Drainage Area _
Drainage Area _
Drainage Area _
On -site Buildings/Lots (so
1,077
On -site Streets (so
5,756
On -site Parking (so
20,444
On -site Sidewalks (so
1,115
Other on -site (so
Future (so
Off -site (so
Existing BUA*** (so
Total (so:
* Stream Class acid Index Number can be determined at: http//portal.ncdertr.org oebAvq&s/csir/classificatioris
"* Imppervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sif ewalks, gravel areas, etc.
*** Report only that amount of existing B UA that Will rentain after development. Do not report any existing BLIA 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.
All Off -Site runoff has been routed around Drainage Area 1 using grassed swales and ditches
Projects in Union County: Contact DWQ Central Office staff to check if the project is located within a Threatened &
Endangered Species watershed that inay be subject to inore stringent storiwater requirements as per 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 htty://://portal.ncdenr.org/web/wq/ws/su/bmp-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.org/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:/Zportal.ncdenr.orgZweb/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 initialed in blue ink. Download the latest versions
for each submitted application package from http://portal,ncdenr.org/web/wq/`ws/su/statesw/forms_docs.
I ii a�
1. Original and one copy of the Stormwater Management Permit Application Form. IA/
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants VA
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 '/q
httl2:/Zwww.envheII2.org/­12ages/onestopexpress.htmI for information on the Express program
Form SWU-101 Version 07Jun2010 Page 4 of 7

and 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.
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including: fah
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.
I. Details of roads, drainage features, collection systems, and stormwater control measures.
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). ,+
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 5I (W7` :,A 'A
elevations and boring logs. Include an 8.5"x11" copy of the NRCS County Soils map with the c• <, it,
project area clearly delineated. For projects with infiltration BMPs, the report should also ��, r.{� 4e
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 SHVVF prior
to subynitta2, [phone].) p
G X r--
11
10
11
A copy of the most current property deed. Deed book: .13768 Page No: 0050
For corporations and limited liability corporations (L.LC): 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 la, 2a, and/or 3a per NCAC 2H.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:Z/www.secretar.y.state.nc.us/Corporations/­CSearch.aspx
Form SWU-101 Version 07Jun2010 Page 5 of

VII. DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For aII 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 Iisting 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:/I12ortal.ncdenr.org/web/wq/wslsu/statesw/forms does. 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: Crag A. Perry, P.E.
Consulting Firm: ms consultants
Mailing Address: 155 US Hwy 70 West
City: Garner State: NC Zip: 27529-3942
Phone: [phone] Fax: (919 _ 779-2305
Email: cperry©msconsultants.com
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type narrre of person listed in Can tact Information, item 2a) HenriLgli Ballance 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) Ernie Rhymer with (print or type name of organization listed in
Contact Information, item Tyr)-_ Qualit?I Oil Companzt, LLC 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 07Jun2010 Page 6 of 7

As the legal property owner l acknowledge, understand, and agree by my signature below, that if MN
designated agent (entity listed in Contact h-dormation, item 1) dissolves their company and/or cancels or
defaults on their lease agreement, or pending sale, responsibility for compliance with the DWQ Stonnwater
permit reverts back to me, the property owner. As the properly owner, it is my responsibility to notify DWQ
immediately and submit a completed Nanie/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 Slater. 143-213.1 and may
result in appropriate enforcement action including the assessment of civil penalties of up to $25,000 per day,
pursuant to NC
GS 1 3-2 5.6.
Signature:2 Date: to /Z 1/
I, , a Notary Public for the State of '1 00-10 / County of
do hereby certify that C 'L� personally appeared
before me this! day of 6Cb r , x I / and acknowledge the clue execu ion of the a plication for
a stormwater permit. Witness my hand and official seal, �1ILC 1
SEAL
My commission expires-412=1/R 17
X. APPLICANT'S CERTIFICATION
1, (print or thjpe name of person listed in Contact Information, item 1a) E r,>Al c -)N'l, t,, c,,,
certify that the information uicluded on this permit application form is, to the best of nny 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 requinnnents of the
applicable stormwater rules under 15A NCAC 21-1.1000, St- 2006-246 (Ph. 11 - Post Construction) or SL 2008-211.
SignaLure:G.
f Dale. 10I t
ff t
a Notary Public for the State oC d{1tn0. County of
do hereby certify that personally appeared
before me this clay of 64*fA�,Qb11 and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, 1
cane s
Nowy PUN* -North caromm
COUNTY OF DAVIDSON
�rC1el1 1- "n8ro� 19MOMILIM
SEAL
My commission Expires s- adds
Form SWU-101 Version 071un2010 Page 7 of 7