NCC205053_NOI Signed Certification_20201105

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO].
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 14.3-215.6B (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
IK-1 The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, orthose persons
directly responsible for gathering the information.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
IKI If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
® I hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: O'REILLY AUTO PARTS
Legally Responsible Organizational Entity: BELTERRA BENSON, LLC
Legally Responsible Person: SCOTT SMITH
Title of Legally onsible Person:
*Signature:Date:
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: 205-968-1701
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

NORTH CAROLINA
Department of the Secretary of State
CERTIFICATE OF AUTHORITY
I, Elaine F. Marshall, Secretary of State of the State of North Carolina, do hereby certify
that
BELTERRA BENSON, LLC
having filed on this date an application conforming to the requirements of the General
Statutes of North Carolina, a copy of which is hereto attached, is hereby granted
authority to transact business in the State ofNorth Carolina.
IN WITNESS WHEREOF, I have hereunto set
my hand and affixed my official seal at the City
of Raleigh, this 3rd day of November, 2020.
Scan to verify online.
Document Id: C202030701277 Secretary of State
Verify this certificate online at https://www.sosnc.gov/verification

NORTH CAROLINA
Department of the Secretary of State
To all whom these presents shall come, Greetings:
I, Elaine F. Marshall, Secretary of State of the State of North Carolina, do hereby certify
the following and hereto attached to be a true copy of
APPLICATION FOR CERTIFICATE OF AUTHORITY
OF
BELTERRA BENSON, LLC
the original of which was filed in this office on the 3rd day of November, 2020.
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IN WITNESS WHEREOF, I have hereunto set my
hand and affixed my official seal at the City of
Raleigh, this 3rd day of November, 2020.
Certification# C202030701277-1 Reference# C202030701277-1 Page: 1 of 4 Secretary Of State
Verify this certificate online at https://www.sosnc.gov/verification

SOSID: 2076596
Date Filed: 11/3/2020 11:08:00 AM
Elaine F. Marshall
State ofNorth Carolina North Carolina Secretary of State
Department of the Secretary of State C2020 307 01277
APPLICATION FOR CERTIFICATE OF AUTHORITY
FOR LIMITED LIABILITY COMPANY
Pursuant to §57D-7-03 of the General Statutes of North Carolina, the undersigned limited liability company hereby applies for a
Certificate of Authority to transact business in the State of North Carolina, and for that purpose submits the following:
1. The name of the limited liability company is Belterra Benson, LLC ;
and if the limited Iiability company name is unavailable for use in the State of North Carolina, the name the limited
liability company wishes to use is N/A
2. The state or country under whose laws the limited liability company was formed is Alabama
3. Principal office information: (,Select either a or b)
a. ❑■ The limited liability company has a principal office.
The principal office telephone number: 205-490-8202
The street address and county of the principal office of the limited liability company is:
Number and Street: 728 Shades Creek Parkway, Suite 130
city: Birmingham State: AL Zip code: 35209 county: Jefferson
The mailing address, if different from the street address, of the principal office of the corporation is:
Number and Street: Same as above.
City: State: Zip Code: County:
b. ❑ The limited liability company does not have a principal office.
4. The name of the registered agent in the State of North Carolina is: C T Corporation System
5. The street address and county of the registered agent's office in the State of North Carolina is:
Number and street:160 Mine Lake Court, Suite 200
City: Raleigh State: NC Zip code:27615 county: Wake
6. The North Carolina mailing address, 1f different from the street address, of the registered agent's office in the State of North
Carolina is:
Number and Street: Same as above.
City:
State: NC Zip Code: County:
BUSINESS REGISTRATION DIVISION
(Revised July 2017)
P.O. BOX 29622
RALEIGH, NC 27626-0622
(Form L-09)
Certification# C202030701277-1 Reference# C202030701277- Page: 2 of 4

APPLICATION FOR CERTIFICATE OF AUTHORITY
Page 2
7. The names, titles, and usual business addresses of the current company officials of the limited liability company are:
(use attachment if necessary) (This document must be signed by a person listed in item 7.)
Name and Title Business Address
John R. Miller, IV, Its Manager 728 Shades Creek Parkway, Suite 130, Birmingham, AL 35209
R. Scott Smith, Its Manager 728 Shades Creek Parkway, Suite 130, Birmingham, AL 35209
Matt Carlson, Its Manager 728 Shades Creek Parkway, Suite 130, Birmingham, AL 35209
Belterra Member, LLC, Its Sole Member 728 Shades Creek Parkway, Suite 130, Birmingham, AL 35209
8. Attached is a certificate of existence (or document of similar import), duly authenticated by the secretary of state or other official
having custody of limited liability company records in the state or country of formation. The Certificate of Existence must be
less than six months old. A photocopy of the certification cannot be accepted.
9. If the limited liability company is required to use a fictitious name in order to transact business in this State, a copy of the
resolution of its managers adopting the fictitious name is attached.
10. (Optional): Please provide a business e-mail address: Privacy -Redaction
The Secretary of State's Office will e-mail the business automatically at the address provided above at no cost when a document
is filed. The e-mail provided will not be viewable on the website. For more information on why this service is offered, please see
the instructions for this document.
11. This application will be effective upon filing, unless a delayed date and/or time is specified: upon filing
This the 30t1day of October , 20 20
Belterra Benson, W5P / 4
Name o i zit ty Company
"of Company
John k. Miller, IV, Its Manager
T}pe or Print Naine and Title
Notes:
1. Filing fee is $250. This document must be filed with the Secretary of State.
BUSINESS REGISTRATION DIVISION
(Revised July 2017)
P.O. BOX 29622
RALEIGH, NC 27626-0622
(Form L-09)
Certification# C202030701277-1 Reference# C202030701277- Page: 3 of 4

John H. Merrill
Secretary of State
P.O. Box 5616
Montgomery, AL 36103-5616
STATE OF ALABAMA
I, John H. Merrill, Secretary of State of Alabama, having custody of the
Great and Principal Seal of said State, do hereby certify that
the entity records on file in this office disclose that Belterra Benson, LLC was
formed in Jefferson County, Alabama on October 8, 2020. The Alabama Entity
Identification number for this entity is 762-327. I further certify that the records do
not disclose that said entity has been dissolved, cancelled or terminated.
In Testimony Whereof, I have hereunto set my
hand and affixed the Great Seal of the State, at the
Capitol, in the city of Montgomery, on this day.
11 /02/2020
Date
20201102000023644 John H. Merrill Secretary of State
Certification# C202030701277-1 Reference# C202030701277- Page: 4 of 4