NCC205823_NOI Application_20210105

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/15/2020 1:09:55 PM (NCG01 NOI Submission)
Approve by Meloy, Michael 12/16/2020 10:57:12 AM (Review- Construction NOI 39192)
• The task was assigned to Meloy, Michael by round robin distribution 12/15/2020 1:10 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 17, 2020 5:00
PM 12/15/2020 1:10 PM
Submit by McCoy, Suzanne 1/5/2021 9:09:06 AM (Payment Verification for NCC205823)
* C4 CStore Holdings II LLC Mt Holly
• McCoy, Suzanne assigned the task to McCoy, Suzanne 1/5/2021 9:08 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 27, 2021 5:00 PM
12/16/2020 10:58 AM

.• SThF� ';
1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 39163
NOI No.
Prior Reviewer Michael Meloy
Name
1a. Project Name * 7-Eleven Mount Holly
1 b. Specific Lot This field may be used to list specffc lot numbers.
Numbers
1 c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 03114104
2. County* Mecklenburg
3. Highway or Street 11112 Mount Holly Road
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Charlotte
5. State * NC
6. Zip Code* 28214
7. Latitude* Enter the latitude in decimal degrees
35.3010
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-80.9870
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin* 12/21/2020
Estimated Construction Project Start Date
10. Date to End* 12/01/2021
Estimated Construction Project End Date

11. SIC (Primary)* Commercial (1542)
Standard Industrial Classification for Development
12. Acres to be 2.53
disturbed* (including off -site borrow and waste areas)
13. Total site area 3.35
(acres) *
14. Post- 56,705.00
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-MECKL-2020-7-Eleven Mount Holly
Tracking ID Assigned automatically
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Catawba River
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 11-(117)
Index No. * NCWaterbody Index Nurrber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Rarmttee Inforrration - Legally Fbsponsible Entity and Individual
...........................................................................................................................................................
Important: The person vvho signs the NOI Certification Form and signs the Certification in Section E of this application
form should be the same person as listed in THIS SECTION, or an authorized responsible individual within the same
organization. That person must be a responsible corporate officer who ovvns 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 NCG010000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1.Organization Legally P9sponsibleEntity
Name * C4 CStore Holdings II, LLC
If pernittee is an individual (i.e., organization does not apply), enter first and last nave in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Timothy
If Corporation, enter Faegistered Agent First Nine
3. Last Name* Sittema
If Corporation, enter Plegistered Agent Last I\bne
3b. Title Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 704-414-7472
Telephone No.*
6. Permittee Mailing Street Address
Address* 121 West Trade Street
Address Line 2
Suite 2550
City
Charlotte
Postal / Zip Code
28202
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address *
r" Yes
Street Address
121 West Trade Street
Address Line 2
Suite 2550
city
Charlotte
Fbstal / Zip Code
28202
State / Province / Fbgion
NC
Country
Mecklenburg
State / Province / Faegion
NC
Country
United States
8. Type of Ojvnership is only individual if an individual is named in B.1. above.
Ownership* Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
_.......................................................................................................................................
1. Primary Site
Jamie
Contact - First
Name *
2. Primary Site
Dillen
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
704-414-7472
Telephone No.
6. Organization
Crosland Southeast
Name
7. Site Contact
Street Address
Mailing Address*
121 West Trade Street
Address Line 2
Suite 2550
City
State / Rovince / Region
Charlotte
NC
Postal / Zip Code
Country
28202
United States
8. Consultant Name
(Optional)
Brandon Plunkett
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
704-527-0800
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
Default is legally responsible person e-n-ail (older NOIs rray not populate)
12. Billing (For Annual Fee correspondence)
Telephone Default is legally responsible person telephone (older NOls rray not populate)

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/27/2020
Approved *
2. E&SC Plan Project LDGP-2020-00226
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Charlotte
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan Letter of Approval modified April 2019 - 7-Eleven
Approval letter or 27KB
Mount Holly.pdf
Grading Permit
Mast be FDFforrrat
6. Site Location Map Mist be RDFforrret (lint 201VB)
Vicinity Map.pdf 368.23KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification NOI - Signed.pdf 84.99KB
Form Mist be RDFforrret
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse 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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Amide or rules of the
Commission implementing this Atcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 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.
rJ 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, or those persons directly responsible for gathering the
information.
* 17 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* rJ If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 I hereby request coverage under the NCG010000 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.
Specify if you are:* r The Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person' (signing on behalf of Legally Responsible
Person named in Part B)
Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who
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 NCG010000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
Type Name* Timothy B. Sittema
Title Manager
Organization Legally Ibsponsible Entity
C4 CStore Holdings II, LLC
Date * 12/15/2020

F. Tracking and COC Info
NOI Tracking No. 39192
NC Reference No.
NCG01-2020-5823
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205823
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5823
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC205823-2020
Invoice Due Date 1/15/2021
Initial Fee $ 100.00
Invoice Status OPEN