SW8180805_CURRENT PERMIT_20200512

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW8 I'4l7$05
DOC TYPE
X CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
oi"JD0p511
YYYYMMDD

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
BRIAN WRENN
Acting Director
May 12, 2020
NORTH CAROLINA
Emfroamental Quality
M.B. SR. Parker Co, LLC
Attn: Mike Bauer, Member/Manager
13230 Raytown Road
Kansas City, MO 64149
Subject: Permit Transfer under N.C.G.S. 143-214.7(c5) / Notice of Inspection
State Stormwater Management Permit No. SW8 t80805
Dollar General — Sunset Beach
Brunswick County
Dear M.T. Bauer.
On April 2, 2020, the Wilmington Regional Office received a complete request to transfer ownership of
the subject state stormwater management permit under the provisions of i 5A NCAC 02H.I 045(1)(c) and
N.C.G.S. 143-214.7(c5). Staff of DEMLR has inspected the project and reviewed the available
documentation, and determined that the project is currently in compliance with the terms and conditions
of the state stormwater permit.
The Division has determined that the provisions of N.C.G.S. 143-214.7(c5) have been met as indicated by
the supporting documents and findings listed below:
I . The successor -owner of the property has submitted a written request for the transfer of the permit.
Reference is made to the attached signed Name/Ownership Change Form;
2. The original permit holder, Par 5 Development Group, LLC, was lawfully and finally divested of
title to the property on which the permitted activity is occurring.
3. The successor -owner holds title to the property on which the permitted activity is occurring.
Reference is made to the deed recorded on June 6, 2019 in DB 4200 PG 975 with Brunswick
County.
4. The successor owner has not proposed any substantial changes to the permitted activity.
5. The updated permit does not impose new or different terms — it merely restates some of the
previous terms to provide you with a better understanding of your obligations under the permit.
By signing the Permit Transfer Application Form, you have accepted the responsibility for complying
with the terms and conditions outlined in this permit, including the correction of the deficiencies outlined
in the inspection report.
The Division is hereby notifying you that the requirements of N.C.G.S. 143-214.7(c5) have been met and
that the subject permit has been transferred on May 12, 2020 and to remind you that this permit shall be
effective until rescinded. For your records, please find enclosed a copy of the updated permit, a copy of
the inspection report, and a copy of the Permit Transfer Request Form. Please keep this cover letter and
updated permit on file at all times. Please note that this transferred, updated, and re -issued permit does
not impose new or different terms; it merely restates and clarifies some of the previous terms to provide
you with a better understanding of your obligations under the permit.
The project is subject to the conditions and limitations as specified in the updated and transferred
permit. Failure to comply with these requirements will result in future compliance problems. Please note
that this permit is not transferable except after notice to and approval by the Division.
If you have any questions, need additional copies of the permit or approved plans, please contact
Christine Hall in the Wilmington Regional Office, at [phone] or [e-mail].
Sincerely,
QNorth�� Carolina Department of Environmental Quality I Division of Energy. Mineral and Land Resources
z::�fD EWilmington Regional Office I l27 Cardinal Drive Extension I Wilmington, North Carolina 28405
noarN cusa�w �
°eiF 910.796.7215

�4 State Stormwater Permit No. SW8 180805
Af Page 2 of 2
Brian Wren,�Cin tDtrDivision of Ener,eral and Land Resources
Enclosures: copy of the Permit Transfer Application Form
copy of the signed and approved Operation & Maintenance Agreement
copy of the certifications
copy of the latest inspection report
copy of the latest application documents
DES/canh: 111StormwaterlPermits & Projects1201&180805 Offsite12020 05 permit 180805
cc: Par 5 Development Group, LLC; Original permittee
Phil Norris, PE; Norris & Tunstall
Wilmington Regional Office Stormwater File

State Stormwater Management
Permit Number SW8 180805
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL AND LAND RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
SERVED BY AN OFF -SITE STORMWATER SYSTEM
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
M. B. SR. Parker Co, LLC
Dollar General — Sunset Beach
400 Sunset Boulevard, Sunset Beach, Brunswick County
FOR THE
construction of built -upon area (BUA) where the stormwater runoff will be treated in a permitted off -
site stormwater system, in compliance with the provisions of Title 15A NCAC 2H .1000 effective
January 1, 2017 (the "stormwater rules") and the approved stormwater management plans,
application, supplement, specifications and other supporting data (the "approved plans and
specifications") as attached and/or on file with and approved by the Division of Energy. Mineral and
Land Resources (the "Division" or "DEMLR") and considered an enforceable part of this permit. The
stormwater runoff from the site will be routed to an infiltration trench operated and maintained by HT
of Ocean Isle Beach, LLC (the "Master Permittee") under the terms and conditions set forth in the
latest version of Stormwater Management Permit No. SW8 060406 (the "Master Permit").
This permit shall be effective from the date of issuance until rescinded 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 approved plans and specifications. The stormwater runoff associated with this project has
been approved to be discharged into an off -site stormwater system permitted under the latest
version of the Master Permit. The stormwater runoff from the permitted built -upon area of this
project must be collected and conveyed to the permitted off -site stormwater system.
The built -upon area allocated to this development by the Master Permit, is 31,425 square feet.
This project proposes 31,425 square feet. This permit does not provide any allocation of built -
upon area for future development.
3. This lot is limited to the amount of built -upon area indicated in this permit and the approved
plans and specifications. The project must maintain a built -upon area less than or equal to the
amount permitted under the Master Permit. A total built -upon area in excess of the maximum
allowed amount will require a modification to the Master Permit prior to construction and/or the
construction of additional stormwater control measures.
Page 1 of 4

State Stormwater Management
Permit Number SW8 180805
II. SCHEDULE OF COMPLIANCE
This permit is issued contingent on the construction of the permitted off -site stormwater system
being complete and in compliance with the latest version of the Master Permit, issued to the
Master Permittee, and as subsequently modified, transferred, or renewed. Prior to the
construction of any built -upon area associated with this permit, the Master Permittee shall have
constructed, operated, maintained, and certified the off -site stormwater system in compliance
with the Master Permit.
2. The project shall be constructed, operated and maintained in accordance with the provisions of
this permit, the approved plans and specifications, and the supporting documentation attached
to this permit and on file with the Division.
3. The stormwater collection system and/or vegetated conveyance system shall be entirely
constructed, vegetated, and operational prior to the construction of any lot development, per the
approved plans and specifications.
4. During construction, erosion shall be kept to a minimum and any eroded areas of the stormwater
collection system and/or vegetated conveyance system will be repaired immediately.
5. All stormwater collection systems, vegetated conveyance systems and/or maintenance
accesses must be located in public rights -of -way, dedicated common areas that extend to the
nearest public right-of-way, and/or permanent recorded easements that extend to the nearest
public right-of-way for the purpose of inspection, operation, maintenance, and repair.
6. The permittee shall at all times provide and perform the maintenance necessary, as listed in the
signed Operation and Maintenance Agreement titled Stormwater Collection System
Maintenance Requirements, a part of the Offsite Supplement, to assure that the permitted
stormwater collection system and/or vegetated conveyance system functions at the approved
design condition to capture and adequately convey stormwater runoff to the permitted off -site
stormwater system. The approved Operation and Maintenance Agreement is incorporated by
reference into this permit and must be followed in its entirety and maintenance must occur at the
scheduled intervals.
7. The final plats for the project must be recorded with the Office of the Register of Deeds. The
recorded plat must reference the Operation and Maintenance Agreement and must also show all
public rights -of -way, dedicated common areas, and/or permanent drainage easements, in
accordance with the approved plans.
8. The permittee is responsible for verifying that the proposed built -upon area for the entire project
does not exceed the maximum allowed by this permit.
9. Upon completion of the project, the permittee shall determine whether or not the project is in
compliance with the permitted plans and take the necessary following actions:
a. If the permittee determines that the project is in compliance with the permitted plans, then
within 45 days of completion, the permittee shall submit to the Division one hard copy and
one electronic copy of the following:
i. The completed and signed Designer's Certification provided in Attachment A noting
any deviations from the approved plans and specifications. Deviations may require
approval from the Division;
ii. A copy of the recorded maintenance agreement;
iii. Unless already provided, a copy of the recorded deed restrictions and protective
covenants; and
iv. A copy of the recorded plat delineating the public rights -of -way, dedicated common
areas and/or permanent recorded easements, when applicable.
b. If the permittee determines that the project is not in compliance with the permitted plans,
the permittee shall submit an application to modify the permit within 30 days of completion
of the project or provide a plan of action, with a timeline, to bring the site into compliance.
Page 2 of 4

State Stormwater Management
Permit Number SW8 180805
10. No person or entity, including the permittee, shall alter any component shown in the approved
plans and specifications. Prior to the construction of any modification to the approved plans, the
permittee shall submit to the Director, and shall have received approval for modified plans,
specifications, and calculations including, but not limited to, those listed below:
a. Any modification to the approved plans and specifications, regardless of size.
b. Redesign of or addition to the approved amount of built -upon area.
c. Further development, subdivision, acquisition, lease or sale of any, all or part of the project
area as reported in the approved plans and specifications.
d. Altering, modifying, removing, relocating, redirecting, or resizing of any component of the
approved stormwater collection system and/or vegetated conveyance system shown on
the approved plan.
e. The construction of any allocated future BUA.
f. The construction of any permeable pavement for BUA credit that was not included in the
approved plans and specifications.
g. The construction of any 57 stone area or trails to be considered a permeable surface that
were not included in the approved plans and specifications.
h. Other modifications as determined by the Director.
11. 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 modified plans and certification in writing to
the Director that the changes have been made.
12. Prior to transfer of the permit, the stormwater collection system and/or vegetated conveyance
system will be inspected by Division personnel. The project and the stormwater collection
system and/or vegetated conveyance system must be in compliance with all permit conditions.
Any items not in compliance must be repaired, replaced or restored to design condition prior to
the transfer.
III. GENERAL CONDITIONS
1. Any individual or entity found to be in noncompliance with the provisions of a stormwater
management permit or the requirements of the stormwater rules is subject to enforcement
procedures as set forth in NCGS 143 Article 21,
2. The issuance of this permit does not preclude the permittee from complying with and obtaining
any and all other permits or approvals that are required in order for this development to take
place, as required by any statutes, rules, regulations, or ordinances, which may be imposed by
any other Local, State or Federal government agency having jurisdiction. Any activities
undertaken at this site that cause a water quality violation or undertaken prior to receipt of the
necessary permits or approvals to do so are considered violations of NCGS 143-215.1, and
subject to enforcement procedures pursuant to NCGS 143-215.6.
3. In the event that the stormwater collection system and/or vegetated conveyance system fail to
perform satisfactorily, the permittee shall take immediate corrective actions. This includes
actions required by this Division and the stormwater rules such as the construction of additional
or replacement stormwater collection system and/or vegetated conveyance system and/or
stormwater control measures. These additional or replacement measures shall receive a permit
from the Division prior to construction.
4. Current Permittee Name or Address Changes: The permittee shall submit a completed "Permit
Information Update Application Form" (available on the Division website) to the Division within
30 days to making any one or more of the following changes:
a. A name change of the current permittee;
b. A name change of the project;
c. A mailing address change of the permittee;
Page 3 of 4

State Stormwater Management
Permit Number SW8 180805
5. Permit Transfer: This permit is not transferable to any person or entity except after notice to and
approval by the Director. The permittee shall submit a completed and signed "Permit Transfer
Application Form" (available on the Division website) accompanied by the required fee and
supporting documentation as listed on the form, to the Division at least 60 days prior to any one
or more of the following events:
a. The sale or conveyance of the project area in whole or in part, except in the case of an
individual lot sale that is made subject to the recorded deed restrictions and protective
covenants;
b. Dissolution of the partnership, corporate, or LLC entity, subject to NCGS 55-14-05 or
NCGS 57D-6-07 and 08;
c. Bankruptcy;
d. Foreclosure, subject to the requirements of Session Law 2013-121;
6. The permittee is responsible for compliance with all of these terms and conditions until such
time as the Division approves the transfer request. Neither the sale of the project, in whole or in
part, nor the conveyance of common area to a third party constitutes an approved transfer of the
permit.
7. The permittee grants Division staff permission to enter the property during normal business
hours for the purpose of inspecting all components of the permitted project.
8. The permit issued shall continue in force and effect until the permittee files a request with the
Division for a permit modification, transfer, or rescission; however, these actions do not stay any
permit conditions.
9. Approved plans, application, supplements, calculations, operation & maintenance agreement,
and specifications for projects are incorporated by reference and are enforceable parts of the
permit. A copy of this permit, application, supplements, operation and maintenance agreement,
and approved plans and specifications shall be maintained on file by the permittee at all times.
10. Unless specified elsewhere, permanent seeding requirements for the vegetated areas must
follow the guidelines established in the North Carolina Erosion and Sediment Control Planning
and Design Manual.
11. 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 for cause as allowed by the
laws, rules, and regulations contained in Title 15A NCAC 2H.1000 and NCGS 143-215.1 et.al.
Permit transferred, updated, and re -issued this the 12t" day of May 2020.
NORTH CAROLINA ENVIRO MENTAL MANAGEMENT COMMISSION
Bri-arrWrenn, Acting Director
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Page 4 of 4

Date Re eiv d Fee Paid ^ Permit Number
NC DEQ Division of Energy, Mineral and Land Resources /�
T: I-1V�?
STATE STORMWATER:
PERMIT TRANSFER APPLICATION FORM
Pursuant to 15A NCAC 02H.1045 and other applicable statues as reference within
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate -DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at: httpJ/deg.rrc.gov/contact/renional-offices.
After this application is accepted, DEMLR will conduct a compliance inspection and report any deficiencies to the
current permittee and/or the proposed permittee. Per the state stormwater rules and the state stormwater permit
conditions, the permit shall not be transferred until:
1. the current permittee resolves all non-compliance issues identified in the inspection report
2_ the current permittee negotiates a resolution with the proposed permittee (in writing and signed by both
entities. The negotiated resolution must identify the necessary actions, the responsible party(ies), and the
timelines to correct the deficiencies. The site must either be found in compliance or a copy of the
negotiated resolution must be submitted prior to the transfer of the permit.); or
3. in the case where a transfer falls- under G. S. 143-214.7(c2) (see also SL 2011-256), the proposed
permittee resolves all non-compliance issues upon acquiring the permit.
Signature requirements for the named signing official (for current and proposed permittee) must meet the following:
• Corporation - a principal executive officer of at least the level of vice-president;
• Limited Liability Company (LLC) - the designated manager; (Documentation from the NC Secretary of
State or other official documentation must be provided that states the titles and positions held by the
person who signed the application (pursuant to 02H.1040) that shows they have legal authority to sign for
the LLC)
• Municipality - a ranking official or duly authorized employee;
• Partnership or limited partnership - the general partner,
• Sole proprietor;
• The signature of the consultant or other agent shall be accepted on this permit transfer application only if
accompanied by a letter of authorization signed by one of the signatories noted in a-e above, as
applicable.
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW8 180805
2. Project name: Dollar General — Sunset Beach
Is this an updated project name from the current permit? ❑ Yes ® No
3. Reason for the pert -nit transfer request:
Change in ownership
scr=ZVE
APR ` 2 2020
Stormwater Permit Transfer Application Form Page 1 of 7 April 27, 2018

B. PERSON(S) WHO HAVE SIGNED THIS FORM (select only one response below)
❑ 1. Both the current and proposed permittees
❑ 2. Only the current permittee of a condominium or planned community (skip Part F & G).
In accordance with G. S. 143-214.7(c2) (see also SL 2011-256), this type of transfer is allowed only
when all of the following items can be truthfully checked:
❑ Any common areas related to the operation and maintenance of the stormwater management
system have been conveyed to the unit owners' association or owners' association in
accordance with the declaration;
❑ The declarant has conveyed at least fifty percent (50%) of the units or lots to owners other than
a declarant (provide documentation per submittal requirements below);.
❑ The stormwater management system is in compliance with the stormwater permit.
DOTE: If subdivision was built prior to 1999, the Declarant's Attorney can make a determination that
the elements of the Planned Community Act (see §47F) have been met by the Declarant for the
subdivision. If the Declarant chooses to use this type of transfer, the determination must be in
writing, signed by the attorney, and submitted to DEMLR with this form.
® 3. Only the proposed permittee (skip Part D below).
In accordance with G.S. 143-214.7(c5) (see also SL- 2013-121), this type of transfer is allowed only
when all of the following items can be truthfully checked:
❑ a. The proposed permittee is either (select one of the following):
® The successor -owner who holds title to the property on which the permitted activity is
occurring or will occur;
❑ The successor -owner who is the sole claimant of the right to engage in the permitted
activity.
❑ b. The current permittee is (select at least one of the following, but all that apply):
❑ A natural person who is deceased.
❑ A. partnership, Limited Liability Corporation, corporation, or any other business
association that has been dissolved
❑ A person who has been lawfully and finally divested of title to the property on which the
permitted activity is occurring or will occur. -
® A person who has sold the property on which the permitted activity is occurring or will
occur,.
❑ Other (please explain):
❑ c, The proposed permittee agrees to the following requirements (all must be selected):
® There will be no substantial change in the permitted activity.
® The permit holder shall comply with all terms and conditions of the permit until such
time as the permit is transferred.
® The successor -owner shall comply with all terms and conditions of the permit once the
permit has been transferred.
ECEIV •+
APR D t4
BY:
Stormwater Permit Transfer Application Form Page 2 of 7 April 27, 2018

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C. SUBMITTAL. REQUIREMENTS
Please mark "Y' to confirm the items are include_ d with this form. Please mark X' if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. A processing fee of five hundred and five dollars ($505.00) per G.S. 143-215.3D(e)(2).
Y 2. Two hard copies (with original siginatures) and one electronic copy of this completed form and the
required items.
Y 3. For proposed permittees that are corporations or LLC's, documentation from the NC Secretary of
State demonstrating that the proposed permittee is a legal and viable entity able to conduct
business in North Carolina.
Y 4. If Part B, Items 1 or 3 of this form is selected, the signed and notarized
applicable O&M agreement(s) from the proposed permittee, as required by the permit.
Y 5. Legal documentation that the property has transferred to the proposed permittee (such as a
recorded deed for the property, uncompleted development and/or common areas) or legal
documentation demonstrating that the proposed permittee is the sole claimant of the right to
engage in the permitted activity. ,
Y 6. If required by the permit and'if the project has been built, a signed, sealed and dated certification
document from a licensed professional stating that the stormwater management system has been
inspected and that it has been built and maintained in accordance with the approved plans.
NIA 7. A copy of the recorded covenants and deed restrictions, if required by the permit. If the project has
been built, documentation that the maximum allowed per lot built -upon area or the maximum
allowed total built -upon area has not been exceeded. If'the project has not been built, the new
owner shall provide a signed agreement to submit final recorded deed restrictions and protective
covenants.
NIA 8. If transferring under G.S. 143-214.7(c2) (i.e., Part S, Item 2 of this form is selected),
documentation verifying that 50% or more of the lots have been conveyed to individuals (not
builders). Copies of the deeds of conveyance or a chart listing the lot number, lot address,
owner's name, conveyance date and steed book and page number are acceptable.
NIA 9. If transferring under G.S. 143-214.7(c5) (i.e., Part B, Item 3 of this form is selected), provide legal
documentation supporting the dissolution of the corporation or documentation supporting the
current permittee-was lawfully and finally divested of title of the property:
N/A 10. A copy of the lease agreement if the proposed permittee is the lessee.
NIA 11. A copy of the pending sales agreement if the proposed permittee is the purchaser,
NIA 12. A copy of the development agreement if the proposed permittee is the developer.
RECEIVE
APR 0 2 2020
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Stormwater Permit Transfer Application Form Page 3 of 7 April 27, 2018

D. CURRENT PERMITTEE INFORMATION AND CERTIFICATION Please be sure to provide Email.
1. Current Permit Holder's Company Name/Organization:
2. Signing Official's Name:
3. Signing Official's Title: _
4: Mailing Address: _. ..
City: State: ZIP
5. Street Address:
City; State: ZIP
6. Phone: ( ) Email:
I, , the current permittee, am submitting this application for a
transfer of ownership for the above listed stormwater permit under the General Statute and Session Law identified
on Page 1 of this application. I hereby notify DEMLR of the sale or other legal transfer of the prope rtylpioject
and/or the stormwater system associated with this permit. I have provided a copy o€,the following documents to
the proposed permittee named in this application form: (select all that apply)
❑ the most recent permit;
❑ the designer's certification for each SCM;
❑. any recorded deed restrictions, covenants, common areas, drainage easements or plats;
❑ the approved plans and/or approved as -built plans;
❑ the approved operation and maintenance agreement;
❑ past maintenance records from the previous permittee (where required);
❑ a copy of the most recent inspection report;
I further attest that this application and request for a permit transfer is accurate and complete to the best of my
knowledge. I attest that I have provided all of the required items per the law to transfer this permit. I understand
that if all required parts of this request are hot completed or if all required supporting information and attachments
listed above are not included, this request package will be returned as incomplete I assign all rights and
obligations as permittee to the proposed permittee named below. I understand that this request to transfer the
permit may not be approved by the DEMLR unless and until the facility is in compliance with the permit.
Signature: Date:
, a Notary Public for the State of
County of , do hereby certify
that personally appeared before me
this the day of 20 , and acknowledge the due
execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature:
My commission expires
Rec�rv�
APR 01201p
Stounwater Permit Transfer Application Form Page 4 of 7 p April 27, 2018

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E. PROPOSED PERMITTEE INFORMATION
I. The proposed permittee is the:
® Property owner (Also complete Part F.)
❑ Home Owners Association (HOA), Property Owners Association (POA), or Unit Owner Association
(UOA) (Also complete Part F.)
❑ Lessee - Attach a copy of the lease agreement. Both the lessee and the property owner will appear on
the permit as co-permittees. If the lease is terminated, responsibility for the permit reverts to the property
owner. (Also complete Parts F & G.)
❑ Purchaser - Attach a copy of the pending sales agreement. The permit will require submission of a copy
of the recorded deed after the purchase has taken place. If the purchase agreement is cancelled the
permit reverts to the property owner. (Also complete Parts F & G.)
❑ Developer - Attach a copy of the development. agreement. Both the developer and the property owner
will appear on the permit as co-permittees. If the development agreement is terminated, responsibility for
the permit reverts to the property owner. (Also complete Parts F & G.)
2. Proposed permittee name (check one of the following and provide the name):
❑ Corporation, LLC, Partnership, Municipality name: M.B. SR. PARKER CO LLC
El
El
HOA I POA I UOA name:
Sole Proprietor
3. Proposed permittee contact information:
Please be sure to provide Email.
a. Signing Official's Name: Mike Bauer
b. Signing Official's Title: rAt�A,*r rfw�tio
c. Mailing Address: 13230 Raytown Road
City: Kansas City State: MO ZIP: 64149
d, Street Address:
City:
e, Phone: [phone] Email: [e-mail]
State: -ZIP:
4. If there is a Management Entity that manages the property for an HOA, POA or UOA, please provide:
Please be sure to provide Email.
a. Management Company or Business name:
b. Contact Name:
c. Mailing Address:
d. City:
e. Phone: (_)
Email:
Title:
State: ZIP:
APR o z 2020 D
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Stormwater Permit Transfer Application Form Page 5 of 7 April 27, 2018

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F. PROPOSED PERMITTEE CERTIFICATION
I, Mike Bauer , hereby notify the DEMLR that I have acquired through sale, lease,
development agreement, or other legal transfer, the project/property covered by the stormwater management
permit and/or the responsibility for constructing and/or operating and maintaining the permitted stormwater
management system. I acknowledge and attest that I have received a copy of: (select all that apply):
❑ the most recent permit;
❑ the designer's certification for each SCM;
❑ any recorded deed restrictions, covenants, common areas, drainage easements or plats;
❑ the approved plans and/or approved as -built plans;
❑ the approved operation and maintenance agreement;
❑ past maintenance records from the previous permittee (where required);
❑ a copy of the most recent inspection report;
Check here if the proposed permittee agrees to be the entity responsible for addressing any compliance
issues outlined in the Compliance Inspection Report. If checked, the proposed permittoe must provide a
written document statement, with a plan of action and schedule" addressed to this office stating that they will
bring the project into compliance upon receipt of the transferred permit. This written plan of action and
schedule" must be received by the Division before the Division will transfer the permit.
I have reviewed the permit, approved plans and other documents listed above, and I acknowledge that I will
comply with the terms and conditions of the permit. I will construct the project's built -upon area as shown on the
approved plans; and I will (construct}, operate and maintain the approved stormwater management system
pursuant to the requirementslistedin the permit and in the operation and maintenance agreement.
Signature: %r Elate: /�•gi2 �� �o�
1, + ' W`� , a Notary Public for the State of
County of do hereby certify that . \C.A.
Personally appeared before me this the _��day of. ( vim` i..— , 20 2.0 , and
acknowledge the due execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signatu
My commission expires 1` j
PAMELA K WOFFORD
Notary Public, Notary Seal
IL State of Missouri
Cass County
Commission # 13498917
My Commission Expires 11-26-2021
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Stormwater Permit Transfer Application Form Page 6 of 7 April 27, 2018

G. PROPERTY OWNER, INFORMATION AND CERTIFICATION
Fill out this section only if the property owner is different from the proposed perrnittee. The permit will revertto
the property owner if the purchase agreement, development agreement or lease expires or is terminated.
Company Name/Organization:
Signing Official's Printed Name:
Signing Official's Title:
Mailing Address:
City:
Phone: (_) Email:
State: ZIP:
I, , hereby certify that I currently own the property identified in
this permit transfer document and acknowledge that the Proposed Permittee listed in'Part F will be purchasing the
property, developing the property on my behalf, and/or leasing the property from rile. A copy of the purchase
agreement, development agreement or the lease agreement, which names the party responsible for the
construction and/or operation and maintenance of the stormwater system, has been provided with the permit
transfer request,
agree to notify DEMLR within 30 days if there are any changes to the purchase, developer or lease agreements
and will submit the applicable completed and signed Permit Information Update Form, or Permit Transfer
Application Form to address these changes. As the legal property owner, I acknowledge, understand, and agree
by rimy signature below, that the permit will revert to me and I will be responsible for complying with the DEML.R
Stormwater permit if the property purchase, lease or developer agreement/contract is cancelled or defaults,
understand that any individual or entity found to be in no with the provisions of the stormwater
management permit or the stormwater rules, is subject to enforcement action as set forth in NC General Statute
(NCGS) 143, Article 21.
Signature of the property owner Date:
<A, a N tary Public for the State of
County of % S , do hereby certify. that
R�► �C� �, L�.1�•�.r personally appeared before me this the ) (,*+t- day of
20_, E3 , and acknowled e e f the forgoing instrument. Witness
my hand and official seal,
(Notary Seal)
Notary Sig
My commission exp
PAMEl PFary Seal
Notary Publ
state of Missouri
Cass County
Commission # 13498917
My Commission Expires 11 26-2021
E51
APR 0 2 20
Stormwater Permit Transfer Application Form Page 7 of 7 1V k- April 27, 2018

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