NCC210464_NOI Application_20210128

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/22/2021 12:33:43 PM (NCG01 NOI Submission)
Approve by Clark, Paul 1/25/2021 5:25:56 PM (Review- Construction NOI 41623)
• The task was assigned to Clark, Paul by round robin distribution 1/22/2021 12:34 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 26, 2021 5:00
PM 1/22/2021 12:34 PM
Submit by Selkane, Aziza 1/28/2021 8:31:29 AM (Payment Verification for NCC210464)
* Paul Lawler
• Selkane, Aziza assigned the task to Selkane, Aziza 1/28/2021 8:29 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 8, 2021 5:00 PM
1/25/2021 5:26 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * Circle K Store - Stanley, NC
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
1 c. Parcel ID List all Rim associated w ith this project.
Number(s) (PIN) 134083
2. County* Gaston
3. Highway or Street 506 HWY 27 S
Address* Street name only is acceptable if no address nunber assigned yet
4.CityorTownship* Stanley
5. State * NC
6. Zip Code* 28614
7. Latitude* Enter the latitude in decinal degrees
35.3530
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-81.0910
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*
01/01/2021
Estinated Construction Project Start Late
10. Date to End*
12/31/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
1.49
disturbed*
(including off -site borrow and waste areas)

13. Total site area 1.44
(acres) *
14. Post- 0.93
construction (Estirreted)
impervious area
(acres) *
NCC Project NCC-GASTO-2021-Circle K Store - Stanley, NC
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 South Stanley Creek
Wate rbody* f\brre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-119-4
Index No.* NCWaterbody Index I inber
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. ^
F2rnittee Inforrration - Legally Fbsponsible Entity and Individual
Important: The person who 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 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.
1. Organization Legally Pesponsible Entity
Name * Circle K Stores Inc.
It pernittee is an individual (i.e., organization does not apply), enter first and last narre 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 * Mark
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Ostoits
It Corporation, enter F;bgistered Agent Last %rre
3b. Title Vice President of Regional Operations
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-774-6700
Telephone No.*
6. Permittee Mailing Street Address
Address* 2550 West Tyvola Road
Address Line 2
Suite 200
Cty
Charlotte
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
Fbstal / Zip Code
28217-4574
V Yes
Street Address
2550 West Tyvola Road
Address Line 2
Suite 200
Qty
Charlotte
Fbstal / Zip Code
28217-4574
State / Ffovince / Fbgion
NC
Country
us
State / Ftovince / Region
NC
Country
us
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
...........................................................................................................................................................................................................................................................................
1. Primary Site
Haytham
Contact - First
Name *
2. Primary Site
Kasem
Contact - Last
Name *
3. Title
Construction Manager
4. Site Contact E-
hkasem1 @circlek.com
mail Address*
5. Site Contact
704-776-6444
Telephone No.*
6. Organization
Circle K Stores Inc.
Name
7. Site Contact
Street Address
Mailing Address*
2550 West Tyvola Road
Address Line 2
Suite 200
City
State / Province / Region
Charlotte
NC
Postal / Zip Code
Country
28217-4574
us
8. Consultant Name
(Optional)
Paul Lawler, PE
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
864-607-2159
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
Default is legally responsible person e-n-ail (older NOts may 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 11/05/2020
Approved *
2. E&SC Plan Project 3674
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Gaston County
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 ESC Approval.pdf 532.17KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrrat (lint 20 NB)
Vicinity Map.pdf 342.57KB
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 documents support
the application. Include additional waterbodies if necessary.
8. NOI Certification eNO1 Certification (signed).pdf 106.62KB
Form Wst be RDF format
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* Mark Ostoits
Title Vice President of Regional Operations
Organization Legally Ibsponsible Entity
Circle K Stores Inc.
Date * 01 /22/2021

F. Tracking and COC Info
NOI Tracking No. 41623
NC Reference No.
NCG01-2021-0464
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC210464
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 464
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC210464-2021
Invoice Due Date 2/24/2021
Initial Fee $ 100.00
Invoice Status OPEN