SW4210501_Change of Permittee Information_20221130

UEMLK USE ONLY
Date Received Fee Paid Permit Number
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER:
PERMIT TRANSFER APPLICATION FORM
Pursuant to 15A NCAC 02H.1045 and other applicable statues as reference within
Only complete applications packages will be accepted and reviewed. This form and the required items (with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at htW.Ildeq.nc.gov/contact/regional-offices.
After this application is accepted, DEMLR will conduct a compliance inspection and report any deficiencies to the
current permittee and/or the proposed permittee. Per the state stormwater rules and the state stormwater permit
conditions, the permit shall not be transferred until:
1. the current permittee resolves all non-compliance issues identified in the inspection report;
2. the current permittee negotiates a resolution with the proposed permittee (in writing and signed by both
entities. The negotiated resolution must identify the necessary actions, the responsible party(ies), and the
timelines to correct the deficiencies. The site must either be found in compliance or a copy of the
negotiated resolution must be submitted prior to the transfer of the permit.); or
3. in the case where a transfer falls under G. S. 143-214.7(c2) (see also SL 2011-256), the proposed
permittee resolves all non-compliance issues upon acquiring the permit.
Signature requirements for the named signing official (for current and proposed permittee) must meet the following:
• Corporation - a principal executive officer of at least the level of vice-president;
• Limited Liability Company (LLC) - the designated manager; (Documentation from the NC Secretary of
State or other official documentation must be provided that states the titles and positions held by the
person who signed the application (pursuant to 02H.1040) that shows they have legal authority to sign for
the LLC)
• Municipality - a ranking official or duly authorized employee,
• Partnership or limited partnership - the general partner;
• Sole proprietor;
• The signature of the consultant or other agent shall be accepted on this permit transfer application only if
accompanied by a letter of authorization signed by one of the signatories noted in a-e above, as
applicable.
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW4210501 8
2. Project name: Dollar General - Burlington
Is this an updated project name from the current permit? ❑ Yes X❑ No
3. Reason for the permit transfer request:
Property being transferred to new ownership
Stormwater Permit Transfer Application Form Page 1 of 7 April 27, 2018

B. PERSON(S) WHO HAVE SIGNED THIS FORM (select only one response below)
X 1. Both the current and proposed permittees
❑ 2. Only the current permittee of a condominium or planned community (skip Part F & G).
In accordance with G. S. 143-214.7(c2) (see also SL 2011-256), this type of transfer is allowed only
when all of the following items can be truthfully checked. -
El Any common areas related to the operation and maintenance of the stormwater management
system have been conveyed to the unit owners' association or owners' association in
accordance with the declaration;
❑ The declarant has conveyed at least fifty percent (50%) of the units or lots to owners other than
a declarant (provide documentation per submittal requirements below);
❑ The stormwater management system is in compliance with the stormwater permit.
NOTE: If subdivision was built prior to 1999, the Declarant's Attorney can make a determination that
the elements of the Planned Community Act (see §47F) have been met by the Declarant for the
subdivision. If the Declarant chooses to use this type of transfer, the determination must be in
writing, signed by the attorney, and submitted to DEMLR with this form.
❑ 3. Only the proposed permittee (skip Part D below).
In accordance with G. S. 143-214. 7(c5) (see also SL 2013-121), this type of transfer is allowed only
when all of the following items can be truthfully checked.
❑ a. The proposed permittee is either (select one of the following):
❑ The successor -owner who holds title to the property on which the permitted activity is
occurring or will occur;
❑ The successor -owner who is the sole claimant of the right to engage in the permitted
activity.
❑ b. The current permittee is (select at least one of the following, but all that apply):
❑ A natural person who is deceased.
❑ A partnership, Limited Liability Corporation, corporation, or any other business
association that has been dissolved
❑ A person who has been lawfully and finally divested of title to the property on which the
permitted activity is occurring or will occur.
❑ A person who has sold the property on which the permitted activity is occurring or will
occur.
❑ Other (please explain):
❑ c. The proposed permittee agrees to the following requirements (all must be selected):
❑ There will be no substantial change in the permitted activity.
❑ The permit holder shall comply with all terms and conditions of the permit until such
time as the permit is transferred.
❑ The successor -owner shall comply with all terms and conditions of the permit once the
permit has been transferred.
Stormwater Permit Transfer Application Form Page 2 of 7 April 27, 2018

C. SUBMITTAL REQUIREMENTS
Please mark " r to confirm the items are included with this form. Please mark X" if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. A processing fee of five hundred and five dollars ($505.00) per G.S. 143-215.3D(e)(2).
Y 2. Two hard copies (with original signatures) and one electronic copy of this completed form and the
required items.
KM 3. For proposed permittees that are corporations or LLC's, documentation from the NC Secretary of
State demonstrating that the proposed permittee is a legal and viable entity able to conduct
business in North Carolina.
Y 4. If Part B, Items 1 or 3 of this form is selected, the signed and notarized
applicable O&M agreement(s) from the proposed permittee, as required by the permit.
Y 5. Legal documentation that the property has transferred to the proposed permittee (such as a
recorded deed for the property, uncompleted development and/or common areas) or legal
documentation demonstrating that the proposed permittee is the sole claimant of the right to
engage in the permitted activity.
Y_ 6. If required by the permit and if the project has been built, a signed, sealed and dated certification
document from a licensed professional stating that the stormwater management system has been
inspected and that it has been built and maintained in accordance with the approved plans.
NA 7. A copy of the recorded covenants and deed restrictions, if required by the permit. If the project has
been built, documentation that the maximum allowed per lot built -upon area or the maximum
allowed total built -upon area has not been exceeded. If the project has not been built, the new
owner shall provide a signed agreement to submit final recorded deed restrictions and protective
covenants.
NA 8. if transferring under G.S. 143-214.7(c2) (i.e., Part B, Item 2 of this form is selected),
documentation verifying that 50% or more of the lots have been conveyed to individuals (not
builders). Copies of the deeds of conveyance or a chart listing the lot number, lot address,
owner's name, conveyance date and deed book and page number are acceptable.
NA 9. If transferring under G.S. 143-214.7(c5) (i.e., Part B, Item 3 of this form is selected), provide legal
documentation supporting the dissolution of the corporation or documentation supporting the
current permittee was lawfully and finally divested of title of the property.
NA 10. A copy of the lease agreement if the proposed permittee is the lessee.
NA 11. A copy of the pending sales agreement if the proposed permittee is the purchaser.
NA 12. A copy of the development agreement if the proposed permittee is the developer.
Stormwater Permit Transfer Application Form Page 3 of 7 April 27, 2018

D. CURRENT PERMITTEE INFORMATION AND CERTIFICATION Please be sure to provide Email.
1. Current Permit Holder's Company Name/Organization: Glandon Forest Equity
2. Signing Official's Name: George Barnes
3. Signing Official's Title: Member/Manager
4. Mailing Address: 3825 Barrett Drive Suite 100
City: Raleigh State: NC ZIP: 27609
5. Street Address: 3825 Barrett Drive Suite 100
City: Raleigh State: NC ZIP: 27609
6. Phone: [phone] Email: gbarnes(&vanguardpa.com
I, George Barnes , the current permittee, am submitting this application for a
transfer of ownership for the above listed stormwater permit under the General Statute and Session Law identified
on Page 1 of this application. I hereby notify DEMLR of the sale or other legal transfer of the property/project
and/or the stormwater system associated with this permit. I have provided a copy of the following documents to
the proposed permittee named in this application form: (select all that apply)
X❑ the most recent permit;
X❑ the designer's certification for each SCM;
X❑ any recorded deed restrictions, covenants, common areas, drainage easements or plats;
X❑ the approved plans and/or approved as -built plans;
X❑ the approved operation and maintenance agreement;
X❑ past maintenance records from the previous permittee (where required);
X❑ a copy of the most recent inspection report;
further attest that this application and request for a permit transfer is accurate and complete to the best of my
knowledge. I attest that I have provided all of the required items per the law to transfer this permit. I understand
that if all required parts of this request are not completed or if all required supporting information and attachments
listed above are not included, this request package will be returned as incomplete I assign all rights and
obligations as permittee to proposed ermittee named below. I understand that this request to transfer the
permit may not be approv b t Runless and until the facility is in compliance wit he permit.
Signature: Date:'
I, k jkf�,X Neu mx` fk 1 L _�Ckn --) , a Notary Public for the State of
�,AOXA 11 0 c-,3r k County of Frc>r��L� , do hereby certify
that Y I personally appeared before me
this the l`7 day of 20 2a , and acknowledge the due
execution of the forgoing instrument. Witness my hand and official seal, 5t%1►141111putrid"
(Notary Seal)
Notary Signature: nature: (�- 1 V
My commission expires dL-p-OS- 2:x)
-Y
s� P
�`f��f6fdllllill r qi=,i�ex'`t�
Stormwater Permit Transfer Application Form Page 4 of 7 April 27, 2018

E. PROPOSED PERMITTEE INFORMATION
1. The proposed permittee is the:
X❑ Property owner (Also complete Part F.)
❑ Home Owners Association (HOA), Property Owners Association (POA), or Unit Owner Association
(UOA) (Also complete Part F.)
❑ Lessee - Attach a copy of the lease agreement. Both the lessee and the property owner will appear on
the permit as co-permittees. If the lease is terminated, responsibility for the permit reverts to the property
owner. (Also complete Parts F & G.)
❑ Purchaser -Attach a copy of the pending sales agreement The permit will require submission of a copy
of the recorded deed after the purchase has taken place. If the purchase agreement is cancelled the
permit reverts to the property owner. (Also complete Parts F & G.)
❑ Developer - Attach a copy of the development agreement. Both the developer and the property owner
will appear on the permit as co-permittees. if the development agreement is terminated, responsibility for
the permit reverts to the property owner. (Also complete Parts F & G.)
2. Proposed permittee name (check one of the following and provide the name):
X❑ Corporation, LLC, Partnership, Municipality name: Dorothy Wilson Family Trust 3
❑ HOA 1 POA 1 UOA name:
❑ Sole Proprietor
3. Proposed permittee contact information:
Please be sure to provide Email.
a. Signing Official's Name: William H. Wilson Sr
b. Signing Official's Title: Trustee
c. Mailing Address: c/o William H. Wilson Sr Trustee - 221 Fieldstone Drive
d. City: Burlington State: NC ZIP: 27215
e. Street Address:
City: State: ZIP
Phone: [phone] Email: wwilsonsr real worldtriad.com
4. If there is a Management Entity that manages the property for an HOA, POA or UOA, please provide:
Please be sure to provide Email.
a. Management Company or Business name: NA
b. Contact Name: Title:
c. Mailing Address:
City:
e. Phone: (_) Email:
State: ZIP:
Stormwater Permit Transfer Application Form Page 6 of 7 April 27, 2018

F. PROPOSED PERMITTEE CERTIFICATION
I,- Dorothy Wilson Family Trust 3, hereby notify the DEMLR that I have acquired through sale, lease, development
agreement, or other legal transfer, the project/property covered by the stormwater management permit and/or the
responsibility for constructing and/or operating and maintaining the permitted stormwater management system. I
acknowledge and attest that I have received a copy of: (select all that apply):
X❑ the most recent permit;
X❑ the designer's certification for each SCM;
X❑ any recorded deed restrictions, covenants, common areas, drainage easements or plats;
X❑ the approved plans and/or approved as -built plans;
X❑ the approved operation and maintenance agreement;
X❑ past maintenance records from the previous permittee (where required);
X❑ a copy of the most recent inspection report;
❑ Check here if the proposed permittee agrees to be the entity responsible for addressing any compliance
issues outlined in the Compliance Inspection Report. If checked, the proposed permittee must provide a
written document statement, with a "plan of action and schedule" addressed to this office stating that they will
bring the project into compliance upon receipt of the transferred permit. This written "plan of action and
schedule" must be received by the Division before the Division will transfer the permit.
I have reviewed the permit, approved plans and other documents listed above, and I acknowledge that I will
comply with the terms and conditions of the permit. I will construct the project's built -upon area as shown on the
approved plans; and I will {construct), operate and maintain the approved stormwater management system
pursuant to the r u' ements listed in the qer rit and in the operation and maintenance agreement.
Signature:.: / +� �e Date:
2 -2/
I, L- U, ems, V , a Notary Public for the State of 1`J C
County of A -, do hereby certify that U kLLL - t-t • WIwi,,, k,
personally appeared before me this the { day of _tiu 20 'Z ,and
acknowledge the due execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature --
My commission expires 4 -?_9 2T:5
Patel L. Oertel, Ili
Notary Public
AlamanCe County;.NC
Stormwater Permit Transfer Application Form Page 6 of 7 April 27, 2018

G. PROPERTY OWNER INFORMATION AND CERTIFICATION
Fill out this section only if the property owner is different from the proposed permittee. The permit will revert to
the property owner if the purchase agreement, development agreement or lease expires or is terminated.
Company Name/Organization: NA
Signing Official's Printed Name:
Signing Official's Title:
Mailing Address:
City:
Phone: (_) Email:
State: ZIP :
I, , hereby certify that I currently own the property identified in
this permit transfer document and acknowledge that the Proposed Permittee listed in Part F will be purchasing the
property, developing the property on my behalf, and/or leasing the property from me. A copy of the purchase
agreement, development agreement or the lease agreement, which names the party responsible for the
construction and/or operation and maintenance of the stormwater system, has been provided with the permit
transfer request.
I agree to notify DEMLR within 30 days if there are any changes to the purchase, developer or lease agreements
and will submit the applicable completed and signed Permit Information Update Form, or Permit Transfer
Application Form to address these changes. As the legal property owner, I acknowledge, understand, and agree
by my signature below, that the permit will revert to me and I will be responsible for complying with the DEMLR
Stormwater permit if the property purchase, lease or developer agreement/contract is cancelled or defaults. I
understand that any individual or entity found to be in noncompliance with the provisions of the stormwater
management permit or the stormwater rules, is subject to enforcement action as set forth in NC General Statute
(NCGS) 143, Article 21.
Signature of the property owner Date: ;f—�
I, __ ?CAei 1 (� -U eel`-k, , a Notary Public for the State of
�JCXA, Cakk" County of Pkxyy,V NBC_ , do hereby certify that
�•.iAaau� K- V llu_ personally appeared before me this the Oil day of
20 2L , and acknowledge the due execution of the forgoing instrument. Witness
my hand anc fficial seal,
(Notary Seal)
Notary Signature
My commission expires L( `Z-6t
Stormwater Permit Transfer Application Form Page 7 of 7 April 27, 2018