SW3160501_CURRENT PERMIT_20160706

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO. SW
DOC TYPE CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE`j�(Ofj 7f (D
YYYYMMDD

Energy. Mineral
and Land Resources
ENVIRONMENTAL OIIALITV
PA'r MCCRORY
ern.,,,,,.
DONALD R. VAN DER VAART
S""l..%
TRACY DAVIS
July 6, 2016
Mr. Shawn Nelson o G
Senior Vice President, Sales
Intertape Polymer Corporation �09 1'b
100 Paramount Drive, Suite 300 m �7 F�
Sarasota, FL 34232 0<%'
o
Subject: Stormwater Permit No. SW3160501 �cco
Intertape Polymer Corporation in Cabarrus County, North Carolina
Dear Mr. Nelson:
The Division of Energy, Mineral, and Land Resources (DELMR), received a complete Stormwater
Management Permit Application for the subject project on July 5, 2016. 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 Section NCAC 2H.1000. We are forwarding Permit No. SW3160501, dated July 6,
2016, for the construction, operation and maintenance of the subject project and the stormwater system.
This permit shall be effective from the date of issuance until July 5, 2024, or until rescinded and shall be
subject to the conditions and limitations as specified therein, and does not supersede any other agency
permit that may be required.
If any parts, requirements, or limitations contained in this permit are unacceptable, you have the right to
request an adjudicatory hearing by filing a written petition with the Office of Administrative Hearings
(OAH). The written petition must conform to Chapter 150B of the North Carolina General Statutes. Per
NCGS 143-215(e) the petition must be filed with the OAH within thirty (30) days of receipt of this
permit. You should contact the OAH with all questions regarding the filing fee (if a filing fee is required)
and/or the details of the filing process at 6714 Mail Service Center, Raleigh, NC 27699-6714, or via
telephone at 919A31-3000, or visit their website at www.NCOAli.com. Unless such demands are made
this permit shall be final and binding.
This project will be kept on file at the Mooresville Regional Office. If you have any questions, or need
additional information concerning this matter, please contact Mike Randall at [phone]; or
[e-mail].
Sincerely,
Jot- Tracy E. Davis, PE, CPM, Director
cc: SW3160501 File, Mooresville Regional Office
cc: Jason Branch, Intertape Polymer Corporation
Gregory T. Welsh, PE Burton Engineering Associates
State of Nonh Carolina J Environmental Quality I Energy. Mineral and land Resources
1612 Mail Service Center � Raleigh. North Carolina 27699-1612
919-807-6375

State Stormwater Permit
Permit No. SW3160501
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT QUALITY
STATE STORMWATER MANAGEMENT PERMIT
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
Intertape Polymer Corporation o
OP
Cabarrus County, in Midland North Carolina co �!
FOR THE
rn
construction, operation and maintenance of two dry detention basins and sand filters in
compliance with the provisions of 15A NCAC 2H .1000 (hereafter referred to as the
"stormwater rules') and the approved stormwater management plans and specifications
and other supporting data as attached and on file with and approved by the State and
considered a part of this permit.
This permit shall be effective from the date of issuance until July 6, 2024, 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.
The two dry detention basins and sand filters are approved for the management of
stormwater runoff as described in the application documents and as shown on the
approved plans.
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.
4. The runoff from all built -upon area within the permitted drainage area of this project
must be directed into the two dry detention basins and sand filters.
5. The built -upon areas associated with this project shall be located at least 30 feet
landward of all perennial and intermittent surface waters.
Page 1 of 4

State Stormwater Permit
Permit No. SW3160501
It. SCHEDULE OF COMPLIANCE
During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
2. The permittee shall at all time provide the operation and maintenance necessary to
assure the two dry detention basins and sand filters permitted 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
r media, planting media, underdrains, catch basins and piping.
g. Access to the cell and outlet structure must be available at all times.
3. Records of maintenance activities must be kept for each of. the two dry detention
basins and sand filters. The reports will indicate the date, activity, name of person
performing the work and what actions were taken.
4. The permittee shall submit an annual summary report of the maintenance and
inspection records for each of the two dry detention basins and sand filters. The
report shall summarize the inspection dates, results of the inspections, and the
maintenance work performed at each inspection.
5. The two dry detention basins and sand filters shall be constructed in accordance
with the approved plans and specifications, the conditions of this permit, and with
other supporting data.
6. 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 two dry detention basins and sand filters 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.
7. 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.
8. The permittee shall submit to the Director and shall have receivedapproval 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.
Page 2 of 4

State Stormwater Permit
Permit No. SW3160501
9. A copy of the approved plans and specifications shall be maintained on file by the
Permittee for a minimum of eight years from the date of the completion of
construction.
10. 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
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 State,
accompanied by the supporting documentation. The approval of this request will be
considered on its merits and may or may not be approved.
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 State, 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 DEQ Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
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.
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.
Page 3 of 4

State Stormwater Permit
Permit No. SW316050,1
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 21-1.1000, 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 7"' day of July, 2016.
Director Division of Energy, Mineral, and Land Resources
Page 4 of 4

State Stormwater Permit
Permit No. SW3160501
Intertape Polymer Corporation
Cabarrus County in Midland, North Carolina
Designer's Certification
I, , as a duly registered in the
State of North Carolina, having been authorized to observe (periodically/ weekly/
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.
Noted deviations from approved plans and specification:
Signature
Registration Number
Date
SEAL
cc: NCDEQ-DEMLR Regional Office
Page 1 of 1

DEMLRUSEONLY -.,. ..• .., -°-..
' Date Received
Fee
Pr 't N ber
Applicable Rules: ❑ Coastal SW -1995 0 Coastal SW - 2008 ❑ 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 Energy, Mineral and Land Resources
STORMWATER MANAGEMENT PERMIT APPLICA itgCl�i FORM
This form may be photocopied for use as an original o O
1. GENERAL INFORMATION m U aA
mZzR` J
1. Project Name (subdivision, facility, or establishment name - should be consistent "%h(R 2ct n4re o ns,
specifications, letters, operation and maintenance agreements, etc.):
2. Location of Project (street address): m
13722 Bill McGee Road
City:Midland County:Cabarrus Zip:28107
3. Directions to project (from nearest major intersection):
From NC Hwy 24/27 and Hwy 601, travel south on 601 approximately 2 miles. Turn right on Wallace Road
and then an immediately Right on Bill McGee Road. The project site is on the north side of the Aberdeen.
Carolina Western Railroad
4. Latitude:35° 13' 51.9" N Longitude:80° 31' 12.2" W of the main entrance to the project.
35• TSH Cn.52o
IL PERMIT INFORMATION:
I. a. Specify whether project is (check one): ®New ❑Modification ❑ Renewal w/ Modificationt
tReneruals with modifications also requires SWU-102 — Renewal Application Form
b.If this application is being submitted as the result of a modification to an existing permit, list the existing
permit numberN/A - , its issue date (if known)N/A , 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
3. If this application is being submitted as the result of a previously returned application or a letter from
DEMLR requesting a state stormwater management permit application, list the stormwater project number,
if assigned, N/A and the previous name of the project, if different than currently
proposed, N/A
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: 20 ac of Disturbed Area
❑NPDES Industrial Stormwater Z404/401 Permit: Proposed Impacts WETLANDS
b.If any of these permits have already been acquired please provide the Project Name, Project/Permit Number,
issue date and the type of each permit:INTERTAPE POLYMER GROUP - MASS GRADING - CABAR-2016-
non __ a t In t u
5. is the project located within 5 miles of a public airport? �No "Ye:
If yes, see S.L. 2012-200, Part VI: http://120rtil.ncdeiir.org/web/Ir/i-ules-and-regulations
Form SWU-101 Version Oct. 31, 2013 Pagel of

III. ' CONTACT INFORMATION
I. a. Print Applicant / Signing Official's name and title (specifically the developer, property owner, lessee,
designated government official, individual, etc. who owns the proiect):
Applicant/Organizahon:INTERTAPE POLYMER CORP.
Signing Official & Title:SHAWN NELSON, SENIOR VP, SALES
b.Contact information for person listed in item 1a above:
Street Address:100 PARAMOUNT DRIVE, SUITE 300
City:SARASOTA State:FL Zip:34232
Mailing Address (if opplicoble):SAME
City:
Phone: (941 ) 357-6105
Email:avanore©itape.com
State: Zip:
Fax: ( )
c. 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/(
Signing Official &
b.Contact information for person listed in item 2a above:
Street Address: IDo PQf-AVOW V1+ NIVV SLiI`P- 300
c
City: SarrSn+ct State: FL Zip: 34232-
Mailing Address (if applicable):
City:
Phone:
Email:
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:INTERTAPE POLYMER CORP.
Signing Official & Title:)ASON BRAUCH, OPERATIONS MANAGER
b.Contact information for person listed in item 3a above:
Mailing Address:]00 PARAMOUNT DRIVE, SUITE 300
City:SARASOTA State:FL Zip:34232
Phone: (920 ) 540-0668 Fax: ( )
Email:[e-mail]
4. Local jurisdiction for building permits: CABARRUS COUNTY
Point of Contact:SUSIE MORRIS Phone #: (704 ) 920-2141
Form SWU-101 Version Oct. 31, 2013 Page 2 of 6

IV. - PROJECT INFORMATION
1. In the space provided below, hriefly summarize how the stormwater runoff will be treated.
STORM WATER RUNOFF WILL BE TREATED BY TWO (2) SAND FILTER BMPs
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 YADKIN PEE-DEE River basin.
4. Total Property Area: 40.594 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':40.594 acres
Total project area shall be calculated to exclude the follotoing the normal pool of impounded structures, the area
between the batiks of streams and rivers, the area below the Noranl High Water (NHW) line or Mean High Water
(MHW) line, and coastal wetlands landward from the NHW (or MHW) line. The resultant project area is used to
calculate overall percent built upon area (BUA). Non -coastal roetlands landward of the NHW (or MHW) title may
be included in the total project area.
8. Project percent of impervious area: (Total Impervious Area / Total Project Area) X 100 = 4.51 /40.594 = 11.1 %
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 the 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.
Basin Information
Drainage Area "I
Drainage Area .
Drainage Area
Drama e Area
Receiving Stream Name
MUDDY CREEK
Stream Class *
C
Stream Index Number *
13-17-16
Total Drainage Area (sf)
667,024
On -site Drainage Area (sf)
667,024
Off -site Drainage Area (so
0
Proposed Impervious Area**(so
196,599
Impervious Area** total
29.5
Impervious** Surface Area
Drainage Area 1
Drainage Area
Drainage Area
Drainage Area
On -site Buildings/Lots (sf)
95,818
On -site Streets (so
65,886
On -site Parking (sf)
33,187
On -site Sidewalks (so
1,708
Other on -site (so
0
Future (so
0
Off -site (so
0
Existing BUA*** (sf)
0
Total (so:
196,599
Stream Class and finder Number can be determined at: bttp1/portal. rtcdenr.org/web/wq[ps/csu/classifications
Impervious area is defined as the built upon area including, but not limited to, buildings, roads, parking areas,
sidewalks, gravel areas, etc.
Report only flint amount of existing BUA that will rennin after development. Do not report any existing BUA that
is to be removed and which will be replaced by new BUA.
Form SWU-101 Version Oct. 31, 2013 Page 3 of 6

11. How was the off -site impervious area listed above determined? Provide documentation.
Proicets in Union Countv: Contact DEMLR Central Office strffto check if the project is located within a Threatened &
Endangered Species watershed that may be subject to more stringent stormwater requirements as per 15A 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 htto://oortal.ncdenr.ore/web/wo/ws/su/bmo-manual.
VI. SUBMITTAL REQUIREMENTS
Only complete application packages will be accepted and reviewed by the Division of Energy, Mineral and
Land Resources (DEMLR). A complete package includes all of the items listed below. A detailed application
instruction sheet and BMP checklists are available from
http://port,il.ncdenr.org/web/wq/ws/su/statesw/forms does. The complete application package should be
submitted to the appropriate DEMLR Office. (The appropriate office may be found by locating project on the
interactive online map at http://portal.ncdenr.org/web/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://portaLncdenr.org/web/wq/ws/su/statesw/forms dots.
Initials
1. Original and one copy of the Stormwater Management Permit Application Form.
2. Original and one copy of the signed and notarized Deed Restrictions & Protective Covenants
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
http://www.envhelp.org/_pages/onestopexpress.litml for information on the Express program
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/nt anagementfor
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 ih
mile radius on the map.
7. Sealed, signed and dated calculations (one copy).
8. Two sets of plans folded to 8.5" x 14" (sealed, signed, & dated), including:
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 MI-lW (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.
1. Details of roads, drainage features, collection systems, and stormwater control measures.
in. 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).
Form SWU-101 Version Oct. 31, 2013 Page 4 of 6

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
elevations and boring logs. Include an 8.5"xll" copy of the NRCS County Soils map with the
project area clearly delineated. For projects with infiltration BMPs, the report should also
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 DEMLR to verify the SHINT prior
to submittal, [phone].)
10. A copy of the most current property deed. Deed book: 70 Page No: 0110
11. For corporations and limited liability corporations (LLC): 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 15A 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://www.secret,iry.state.nc.us/Corporafioi)s/CSearcii.aspx
VIL DEED RESTRICTIONS AND PROTECTIVE COVENANTS
For all 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 listing 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://portal.ncdenr.org/web/Ir/state-stormwater-
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 DEMLR, and that they will be recorded prior to the sale of any lot.
Vlll. 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:GREGORYT. WELSH, PE
Consulting Firm: BURTON ENGINEERING ASSOCIATES
Mailing Address:5950 FAIRVIEW ROAD, SUFFE 100
City:CHARLO'ITE State:NC Zip:28210
Phone: (704 ) 553-8881 Fax: (704 ) 553-8860
Ennai l:greg©burtonengineering.com
IX. PROPERTY OWNER AUTHORIZATION (if Contact Information, item 2 has been filled out, complete this
section)
I, (print or type tame of person listed in Contact Information, item 2a) --n4p,}4OP_ %hope( Cotp. , certify that I
own the property identified in this permit application, and thus give permission print o� me of person
listed in Contact Information, item 1a) SkaWvt Ne(Sont with (print or type tame of organization listed in
Contact Information, itent 1a r COf .to develop the project as currently proposed. A copy of
the lease agreement or pending prop rty sales contract has been provided with the submittal, which indicates the
party responsible for the operation and maintenance of the stormwater system.
Fonn S WU-101 Version Oct. 31, 2013 Page 5 of 6

As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner, it is my responsibility to notify DEMLR immediately and
submit a completed Name/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 Statue 143-215.1 and may result in appropriate enforcement
action including tke asses fient o�`fil /nalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Date:
1, C6ttct6' 13✓vG4n„ a Notary Public for the State of tri 51 ✓ } 04r� County of
Sac,va}07-� do hereby certify that 5knu/w Ne(So rJ personally appeared
before me this.�0 day of M" 2014- , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, UA
SEAL
+Psi...:••.. CHARLETTE BROWN
Pry'` Commission # FF 947455
Expires April 6, 2020
Ff,.C,: aca.e rm,rAr r.e imm.x. eoo-aesrois
My commission expires /�.1i?J� '20
X. APPLICANT'S CERTIFICATION
1, (print or type name of person listed in Contact Information, item Ia) 754a,,w n A-ei15u-._
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that the project will be constructed in conformance with the approved plans, that the required deed restrictions
and protective conants ry'H be recorded, and that the proposed project complies with the requirements of the
m a applicable storter r es under A WAC 2H .1000 and any other applicable state stormwater requirements.
Date: {May 1-0' u 11
I, e✓�� -a Notary Public for the State of Goo vi g4l , County of
5"'k-A S 4"L , do hereby certify that ! kciy1✓i we.150 ri personally appeared
before me this day of AIA41_ and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal, CAI
••, CHARLETTE BROWN
i.1 6tz"' Commission # FF 947455
�:•e= Expires April 6, 2020
'+ e�a.arr.0 rmr r.. m..... aowesraie
SEAL
My commission expires (t &', 6 , 2J-�' L U
Form SWU-101 Version Oct. 31, 2013 Page 6 of 6

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aa{ ti•i,� _
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Permit Number:
(to be provided by DB'Q)
Drainage Area Number:
Sand Filter Operation and Maintenance Agreement
f will keep a maintenance record on this BMP. This maintenance record will be kept in a log in a
known set location. Any deficient BMP elements noted in the inspection will be corrected, repaired or
replaced immediately. These deficiencies can affect the integrity of structures, safety of the public, and
the removal efficiency of the BMP.
Important maintenance procedures:
— The drainage area will be carefully managed to reduce the sediment load to the sand filter.
— The sedimentation chamber or forebay will be cleaned out whenever sediment depth exceeds
six inches.
— Once a year, sand media will be skimmed.
— The sand filter media will be replaced whenever it fails to function properly after maintenance.
The sand filter will be inspected quarterly and within 24 hours after every storm event greater than
1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and maintenance will be kept in
a known set location and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired
immediately.
BMI'IelemenE,'. j
Potentrato_roblem -� �Howll;will§remediate'tlie� roblem ,
Entire BMP
Trash/debris is present.
Remove the trash/debris.
Adjacent pavement (if
Sediment is present on the
Sweep or vacuum the sediment as soon as
applicable)
pavement surface.
possible.
Perimeter of sand filter
Areas of bare soil and/or erosive
Regrade the soil if necessary to remove the
gullies have formed.
gully, and then plant a ground cover and
water until it is established. Provide time
and aone-time fertilizer application.
Vegetation is too short or too long.
Maintain vegetation at an appropriate
height.
Flow diversion structure
The structure is clogged.
Unclog the conveyance and dispose of any
sediment offsite.
The structure is damaged.
Make any necessary repairs or replace if
damage is too large for repair.
Forebay or pretreatment area
Sediment has accumulated to a
Search for the source of the sediment and
depth of greater than six inches.
remedy the problem if possible. Remove
the sediment and stabilize or dispose of it
in a location where it will not cause
impacts to streams or the BMP.
Erosion has occurred.
Provide additional erosion protection such
as reinforced turf matting or riprap if
needed to prevent future erosion
problems.
Weeds are present.
Remove the weeds, preferably by hand. If
a pesticide is used, wipe it on the plants
rather than spraying.
Form SW40I-Sand Filter O&M-Rev.4 2009Septl7 Page 1 of 3

";BMP.elernent: `. - '°
',Potential- roblehi'. "`" ,..'.,.,':HowTwillreinediatethe'`roblem.
Filter bed and underdrain
Water is pending on the surface for
Check to see if the collector system is
collection system
more than 24 hours after a storm.
clogged and Flush if necessary. if water
still ponds, remove the top few inches of
filter bed media and replace. If water still
ends, then consult an expert.
Outlet device
Clogging has occurred.
Clean out the outlet device. Dispose of the
sediment offsite.
The outlet device is damaged
Repair or replace the outlet device.
Receiving water
Erosion or other signs of damage
Contact the NC Division of Water Quality
1
have occurred a
401 Oversight Unit at 919-733-1786.
Forst SW401-Sand Filter O&M-Rev.4 2009Septl7 Page 2 of 3

i -'_
Permit Number:
(to be pror'ided br DWQ)
I acknowledge and agree by my signature below that I am responsible for the performance of the
maintenance procedures listed above. I agree to notify DWQ of any problems with the system or prior
to any changes to the system or responsible party.
Project nante:INTERTAPE POLYMER GROUP
BMP drainage area number: I A (EAST SAND FILTER)
Print name:SHAWN NELSON
Title:SENIOR VP, SALES
Address:100 PARAMOUNT DRIVE, SUITE 300 -- SARASOTA, FL -- 24232
Note: The legally responsible party should not be a homeo"mers association unless more than 50% of the lots have been
sold and a resident of the subdivision has been named the president.
I, i��� 3✓va i a Notary Public for the State of
County of Sa.i-a-S o 4� , do hereby certify that
1 ktl n/vt Ne ksory personally appeared before me this ).o day of
M a,^� , 2y Ito , and acknowledge the due execution of the forgoing sand filter
maintenance requirements. Witness my hand and official seal, C_�U�_�
CHARLETTE BROWN
Commission # FF 947455
Expires April 6,2020
?E,;,1:s'� B Aad iNu im, FanNwMa 0.W9S1p1D
SEAL
My commission expires a y s 0
Form SW401-Sand Filter O&M-Rev.4 2009Septl7 Page 3 of 3