SW4210501_Supplemental Info Review_20221130

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/30/2022 8:29:07 AM (Supplemental Submittal)
Submit by Tran, Kieu M 12/5/2022 10:46:40 AM (Supplemental Info Submittal)
• The task was assigned to Tran, Kieu M 11/30/2022 8:29 AM

Submittal from 11/30/2022
Permit Information:
Please provide specific permit details below.
What Type of Permit? Choose one:
* NPDES Industrial or MS4 Permit
• State Stormwater (Post -Construction) Permit
Other
Permit Number* SW4210501
Begins with "SW", "NCG", or "NCS'
What DEQ Office is Reviewer: Please correct if misidentified, close this review form, and reassign task to the appropriate contact.
the Primary Contact? • Central Office
*
Washington Regional Office (Attn: Carl Dunn)
Wilmington Regional Office (Attn: Christine Hall)
Project Name*
Dollar General - Burlington
Owner/Operator*
Dorthy Wilson Family Trust 3
County:
Alamance
Submitter Name: *
George Barnes
Who is submitting this information?
E-mail Address:*
[e-mail]
Phone Number*
919-459-2601
Additional E-mail for
(Optional)
Submittal
Confirmation:
State Stormwater (Post -Construction) Information Uploads
Choose file type and upload attachment (Reviewer may remove unnecessary submittals)
File Type* O&M Agreement/Plan
File Upload Click the upload button, or drag and drop files to attach
O&M and deed.pdf 159.41 KB
Only PDF files are accepted.
File Type* Change of Permittee Information
File Upload Click the upload button, or drag and drop files to attach
Transfer Packet.pdf 240.46KB
Only PDF files are accepted.

Uploads contain NO
Confidential YES
Information* NOTE: The following information cannot be claimed as confidential: the name and address of any permit applicant
or permittee, permit applications, permits, effluent data, information required by NPDES application forms provided
by the Director inclusive of all forms and attachments [Ref. 40 CFR 122.7(b) and (c)].
Notes about the attachments:
* By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
• I agree that submission of this Supplemental Information form is a "transaction" subject to Chapter 66, Article 40 of the
NC General Statutes (the "Uniform Electronic Transactions Act')
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
• I intend to electronically sign and submit the Supplemental Information Upload form.
Full Name:* George Barnes
Signature:
p f, pamv
Date Submitted: 11/30/2022

Initial Review
Verify Permit No.* IMPORTANT. REVIEWER SHOULD VERIFY and revise here if necessary.
SW4210501
Who needs a Copy?* Reviewer selections will only be required for offices checked here.
Central Office Staff
Regional Office Stormwater Contact
State Stormwater RO Staff
No Copy Needed
Central Office Reviewer:*
Notifies CO Staff with Email
Jim Farkas
Any Comments or
Added Info for CO
Staff Reviewer?
Review Date* 12/05/2022