SWA000216_Application Form_20230801

DEMLR USE ONLY
Date Received Fee Paid Permit Number
SW Program(s): ❑Coastal SA-HQW ❑Coastal SA-ORW 0 Coastal FW-ORW ❑Coastal Other
❑Non-coastal HQW ❑Non-coastal ORW ❑Urbanizing Areas ❑USMP
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER FAST TRACK PROCESS:
"AUTHORIZATION TO CONSTRUCT" (ATC) PERMIT APPLICATION FORM
Link to Application Instructions
A. ELIGIBILITY FOR FAST-TRACK PERMITTING
To be considered for a Fast Track ATC Permit, all of the items below must be checked. If any item cannot
be checked, then the project must apply under the Standard Permitting Process.
® The project and all SCMs (including existing SCMs associated with the project)will meet all applicable
requirements of 15A NCAC 02H .1000 - .1062, including the Minimum Design Criteria (MDC), upon project
completion.
® The project is not proposing an alternative design.
® The project is not claiming an exemption from the MDC based on vested rights, a waiver or a Director's
Certification.
® The project is not out of compliance with an existing stormwater permit or any other environmental permit.
® The project is not applying for an offsite permit, an exemption, or a minor modification (as defined in 15A
NCAC 02H .1002(25)) to an existing state stormwater permit.
® The project application bears the signature and seal of a professional licensed pursuant to either Chapter 89A
or 89C of the NC General Statutes.
® I understand that at project completion, an application with the as-built stormwater plans (as described in 15A
NCAC 02H .1044 must be submitted, and DEQ will review the as-built stormwater plans to confirm
compliance with the MDC. Approval of the as-built stormwater plans will be required before the Erosion and
Sedimentation Control Plan for the project may be closed out.
® I understand that the Fast Track ATC Permit will expire five years after the date of issuance.
B. GENERAL INFORMATION
1 Project Name: Circle K- Expansion 2723205 - Old US Hwy 52 & Hickory Tree Rd
2 Previous Project Name (if applicable)
3 Location of Project(street address): 106 Hickory Tree Road
City:Winston-Salem County:Davidson Zip:27107
4. Directions to project(from nearest major intersection):
Northwest corner of intersection of Hickory Tree Rd & Old US Hwy 52 in Winston-Salem, NC
5. Latitude:35° 58' 06.19" N Longitude:-80° 13'23.93"W of the main entrance to the project.
C. PERMIT INFORMATION
1. Specify whether project is (check one):
® New, no previous application
❑ New, replacing a previous Fast Track ATC Permit-- provide previous permit number: SWA
By choosing this option, you are also requesting that DEQ rescind the previous Fast Track ATC Permit
upon issuance of the new Fast Track ATC Permit.
Stormwater Fast Track ATC Application Form Page 1 of 9 Feb. 10. 2018

❑ Major Modification, replacing an existing stormwater permit—provide existing permit number: SW
Status of construction? ❑ Not Started ❑ Partially Completed ❑ Completed
Major modifications must be submitted by the original permittee and are allowed only if the SW permit is
not expired. Minor modifications must use Standard Permitting Process. By choosing this option, you
are also requesting that DEQ rescind the previous SW Permit upon issuance of the new Fast
Track ATC Permit.
❑ Transfer of existing Fast Track ATC Permit—provide existing ATC permit number: SWA
2. Applicable state stormwater program(s) (check all that apply):
❑ Coastal SA-HQW ® Urbanizing Areas (Phase 2)
❑ Coastal SA-ORW ❑ Non-Coastal HQW
Is any portion of the project within 575 feet
of SA-ORW waters? ❑ Yes ❑ No ❑ Non-Coastal ORW
❑ Coastal Freshwater ORW ❑ USMP
❑ Coastal—Other
3. Other Permits (as applicable; write "NA"for those permit types that are not applicable):
Project Name Permit/Appl Issue Date Other Information
No.
CAMA Major NA NA
Erosion & Circle K- Expansion 2723205- In process Disturbed Area 0.95
Sedimentation Control Old US Hwy 52 & Hickory Tree acre
Rd
NPDES Industrial NA NA
Stormwater
404/401 Permit NA Proposed Impacts
If/ac
4. Local jurisdiction for building permits: Davidson County
Point of Contact:Beau Chollett Phone#: (336 ) 242-2239
D. CONTACT INFORMATION
1. Applicant/Financially Responsible Party (may be an Organization):Circle K Stores Inc.
Signing Official Name &Title:Meredith Will Rice Jr. -Vice President
Street Address:1100 Situs Court; Suite 100
City:Raleigh State:NC Zip:27606
Mailing Address (if different):NIA
City:N/A State:N/A Zip:N/A
Phone: (919) 774-6700 Fax: (
Email: [e-mail]
2. If the Applicant is a Corporation or LLC (Address must match address on file with NC Dept of the Secretary of
State):
Name of Registered Agent:Meredith Will Rice, Jr.
Mailing Address:1100 Situs Court; Suite 100
City:Raleigh State:NC Zip:27606 _
Phone: (919) 774-6700 Fax: (
Email:[e-mail]
Stormwater Fast Track ATC Application Form Page 2 of 9 Feb. 10, 2018

3. The Applicant is the (check all that apply):
• Property Owner
❑ Lessee (Attach a copy of the lease agreement& complete Item 4.)
® Purchaser(Attach a copy of the pending sales agreement& complete Item 4.)
❑ Developer(Attach a copy of the development agreement& complete Item 4.)
4. If the Applicant is NOT the Property Owner (skip to Item 5 if the Applicant IS the Property Owner):
Property Owner Name/Organization:Hubbard Realty of Winston-Salem, Inc.
Signing Official &Title:John-Lewis Godfrey-Vice President
Street Address:1598 Westbrook Plaza Drive, Suite 200
City:Winston-Salem State:NC Zip:27103
Mailing Address (if applicable):1598 Westbrook Plaza Drive, Suite 200
City:Winston-Salem State:NC Zip:27103
Phone: (336) 723-0303 _ Fax: (
Email:[e-mail]
5. The licensed Design Professional that will be retained for the duration of the project, who may provide
information on the Applicant's behalf, and who will prepare and certify the as-built package:
Consulting Engineer/Landscape Architect:Jacob Dooley, PE
Consulting Firm: Timmons Group
Mailing Address:5410 Trinity Road; Suite 102
City:Ra leigh State:NC Zip:27607
Phone: (919 ) 866-4937 Fax: (
Email:[e-mail]
6. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name &Title:
Organization:
Mailing Address:
City: State: Zip:
Phone: ( ) Fax: (
Email:
E. PROJECT INFORMATION
1. Specify the type of project (check one): ❑ Low Density ® High Density
2. Briefly summarize how the stormwater runoff will be treated/conveyed:
Stormwater will be conveyed through an underground pipe network to a bio-retention pond.
3. Stormwater runoff from this project drains to the Yadkin Pee-Dee River basin(s).
4. Receiving water information (if more than 3 receiving waters, provide additional information on an attached sheet):
Receiving Receiving Receiving
Water 1 Water 2 Water 3
Receiving Stream Name Fryes Creek Fryes Creek
Stream Classification C C
Stream Index Number 12-94-15 12-94-15
Stormwater Fast Track ATC Application Form Page 3 of 9 Feb. 10, 2018

3. The Applicant is the (check all that apply):
• Property Owner
❑ Lessee (Attach a copy of the lease agreement& complete Item 4.)
® Purchaser(Attach a copy of the pending sales agreement& complete Item 4.)
❑ Developer(Attach a copy of the development agreement& complete Item 4.)
4. If the Applicant is NOT the Property Owner (skip to Item 5 if the Applicant IS the Property Owner):
Property Owner Name/Organization:Taylor Development Group, LLC
Signing Official &Title:H. Chris Ramm
Street Address:4505 Country Club Road, Suite 220
City:Winston-Salem State:NC _ Zip:27104
Mailing Address (if applicable):4505 Country Club Road, Suite 220
City:Winston-Salem State:NC Zip:27104
Phone: (336) 422-1277 Fax: (
Email:[e-mail]
5. The licensed Design Professional that will be retained for the duration of the project, who may provide
information on the Applicant's behalf, and who will prepare and certify the as-built package:
Consulting Engineer/Landscape Architect:Jacob Dooley, PE
Consulting Firm: Timmons Group
Mailing Address:5410 Trinity Road; Suite 102
City:Ra leigh State:NC Zip:27607
Phone: (919 ) 866-4937 Fax: (
Email:[e-mail]
6. [OPTIONAL] If you would like to designate another person to answer questions about the project:
Name &Title:
Organization:
Mailing Address:
City: State: Zip:
Phone: ( ) Fax: (
Email:
E. PROJECT INFORMATION
1. Specify the type of project (check one): ❑ Low Density ® High Density
2. Briefly summarize how the stormwater runoff will be treated/conveyed:
Stormwater will be conveyed through an underground pipe network to a bio-retention pond.
3. Stormwater runoff from this project drains to the Yadkin Pee-Dee River basin(s).
4. Receiving water information (if more than 3 receiving waters, provide additional information on an attached sheet):
Receiving Receiving Receiving
Water 1 Water 2 Water 3
Receiving Stream Name Fryes Creek Fryes Creek
Stream Classification C C
Stream Index Number 12-94-15 12-94-15
Stormwater Fast Track ATC Application Form Page 3 of 9 Feb. 10, 2018

5. Project area and density information:
Total Property Area 74,923 sf
Total Surface Water Area 0 sf
Considered to include:
• the normal pool of impounded structures;
• the area between the banks of streams and rivers;and
• the area below the Normal High Water(NHW)line or Mean High Water(MHW)line.
Total Coastal Wetlands Area 0 sf
Considered to include: coastal wetlands landward from the NHW(or MHW)line.
Total Project Area 74,923 sf
Excludes the surface water area and coastal wetland area identified above.
May or may not be the same as Property Area.
Built-Upon Area(BUA)associated with Existing Development 36,530 sf
"Existing development"means those projects that are built or those projects that have established a
vested right under North Carolina law as of the effective date of the state storm water program or
applicable local government ordinance to which the project is subject.
Proposed New BUA 11,889 sf
Includes proposed new BUA that is not associated with existing development.
"BUA"is defined in N.C.G.S. 143-214.7(b2). It includes, but is not limited to:buildings, roads,parking
areas, sidewalks, and some gravel areas. The design volume of SCMs must take into account the runoff
from build out from all surfaces draining to the SCM in accordance with 15A NCAC 02H.1050(1).
Project Density
w/Existing Development: Project Density=(New BUA]/(Total Project Area—Existing BUA]x 100 or 31 %
w/o Existing Development: Project Density=(New BUA]/Total Project Area]x 100
6. Anticipated construction start date 10/2023
7. Is the project located within 5 miles of a public airport? ® No ❑ Yes
If Yes,'see S.L. 2012-200, Part VI: http://www.ncleg.net/Sessions/2011/Bills/Senate/PDF/S229v6.pdf and
DEQ Stormwater Design Manual Chapter E-4 Airports.
8. For projects in Union County: Contact DEMLR Central Office Stormwater staff at 919-707-9200 to determine
if the project is located within a Threatened& Endangered Species watershed that may be subject to more
stringent storm water requirements per 15A NCAC 02B .0600.
Stormwater Fast Track ATC Application Form Page 4 of 9 Feb. 10, 2018

F. SUBMITTAL REQUIREMENTS
Submit the application package to the appropriate DEMLR Regional Office (Coastal, SA Waters) or DEMLR
Central Office (Urbanizing Areas Ph 2, USMP, Non-Coastal HQW/ORW). Only application packages that include
all required items listed below will be accepted and reviewed.
Initial each item below to indicate that the required information is provided in the application package:
Initials
J D. 1 Two original signed hard copies and one electronic copy of this State Stormwater Fast Track
Process "Authorization to Construct" (ATC) Permit Application Form.
2. Permit application processing fee of$505 payable to NCDEQ.
D 3. Two hard copies and one electronic copy of a USGS map identifying the project location
and GPS coordinates for the project. If the receiving water is Class SA or the receiving water
drains to Class SA waters within 1/2 mile of the project boundary, include the '/2 mile radius
on the map. If the project is within 575 feet of Class SA-ORW waters, include the 575-foot
radius on the map.
U 4. Two original signed hard copies and one electronic copy of a site plan depicting the boundary
of the project or project phase currently being permitted, including the locations of SCMs,
streams, wetlands, and buffers.
5. Two hard copies and one electronic copy of a construction sequence that discusses how any
future development on the project may be phased.
J i 6. A copy of the most current property deed. Deed book: 2590/1134/2590 Page No
1826/1962/2016
7. [IF APPLICABLE] When the applicant is a corporation or a limited liability corporation (LLC): Provide
two hard copies and one electronic copy of documentation from the NC Secretary of State, or other
official documentation, which supports the titles and positions held by the persons listed
in Section C.2 per 15A NCAC 2H. 1043(3)(b). The corporation or LLC must be listed as an active
corporation in good standing with the NC Department of the Secretary of State; otherwise, the
application will be returned. https://www.sosnc.gov/search/index/corp
8. [IF APPLICABLE] When the applicant is a Partnership or other person engaging in business under
an assumed name, attach a copy of the Certificate of Assumed Name.
n 9. [IF APPLICABLE] When the applicant is not the property owner: Provide two hard copies and one
electronic copy of lease agreements, affidavits, pending sales agreement, development agreement,
or other documents showing that the applicant has obtained legal rights to submit a stormwater
permit application within the proposed project area.
N/A 10. [IF APPLICABLE] If modifying an existing permit for completed or partially completed projects, a copy
of the designer's certification.
Stormwater Fast Track ATC Application Form Page 5 of 9 Feb. 10, 2018

G. CERTIFICATION OF APPLICANT/ FINANCIALLY RESPONSIBLE PARTY
The Applicant, who is also the Financially Responsible Party, identified in Section D of this form must sign and have
notarized the following guaranty:
I, (print or type name of Applicant/Financially Responsible Party) Meredith Will Rice Jr.
certify that the information included on this permit application form is, to the best of my knowledge, correct and
that:
1. the design has been or will be completed in accordance with the MDC as set forth in Rules 15A NCAC
02H .1050 through .1062, to the best of my knowledge;
2. the completed design meets or will meet the MDC and that the percentage BUA that is the basis for the
design shall not be exceeded, to the best of my knowledge; and
3. As the applicant, I shall maintain a licensed professional of record for the duration of the project
who will prepare and certify the as-built package. If I retain another licensed
professional before the project is complete, then I shall provide an updated
guaranty with the current licensed professional's seal. A licensed professional shall inform
the Division if he is no longer associated with this project.
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath I
agree to provide corrected information should there be any change in the information provided herein.
Meredith Will Rice Jr. Vice President
Type or print name Title or Authority
Signature Date C,L_� ao3
I, '&10rf'1 '/le f a Notary Public� for the State of 47 �ff�`t—!
County of NJOHA1ST'N yt
do hereby certify that / gesed/1i1 i ). Rice
personally appeared before me this .A/61- day of 74eil , and acknowledge the
due ex-cutiOn of tly -,• 'cation fit a stormwater permit. Witness my hand and official seal,
S
SEAL
ROBIN F. ALFORD
Notary Public, North Carolina
Johnston County
My Commission Expires � a
April 23,2023 My commission expires / 3 V 3
Stormwater Fast Track ATC Application Form Page 6 of 9 Feb. 10, 2018

H. DESIGN PROFESSIONAL'S CERTIFICATION
To be completed by the Design Professional identified in Section D.5.
o.o .e. r , attest to the following
1. This application has been reviewed by me and is accurate and complete, to the best of my knowledge;
2. The design has been completed in accordance with the MDC as set forth in Rules 15A NCAC 02H
.1050 through .1062, as applicable;
3. The percentage built-upon area that is the basis for the design will not be exceeded; and
4. I have the expertise, education, and experience required to design the SCMs proposed in this
application in accordance with the MDC as set forth in Rules 15A NCAC 02H .1050 through .1062.
5. I will provide all documents and certified as-built plans in hard copy and electronic format related to
this permit to a new Applicant/Property Owner and to DEMLR upon transfer of this permit to a new
Applicant/Property Owner.
Note: In accordance with N.C.G.S. 143-215.6A and 143-215.6B, any person who knowingly makes any false
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation. In addition, any person
who knowingly makes any false statement, representation, or certification in any application may be reported to
the appropriate NC professional licensing board.
Signature. /')() Date: 5`(V Z )
tt tIIIII
CA,4
0. 0` tiy '
: SEAL
SEAL <OP
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Stormwater Fast Track ATC Application Form Page 7 of 9 Feb. 10, 2018

I. PROPERTY OWNER'S AUTHORIZATION (IF APPLICANT IS NOT THE PROPERTY OWNER)
I, (print or type name of the Property Owner) -N,((Or—bPviC(O pvY eiAi-6kve.,o) L i d , certify that I
own the property identified in this permit application, and thus give permission to (print r type name of Applicant)
Meredith Will Rice Jr. with (print or type name of Applicant's
organization) Circle K Stores. Inc. to develop the project as
currently proposed. A copy of the lease agreement or pending property sales contract has been provided with the
submittal, which indicates the party responsible for the operation and maintenance of the stormwater system.
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
the assessment of civil enalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
•
Signature • Date: Zir•,202f
I, ,rJ'R fr,7 , a Notary Public for the State of A/C-
County of F vim., C1v , do hereby certify that //e4/1 Cc/e-or
personally appeared before me this 2 8 day of , �-e , ?07-3 , and acknowledge the
due execution of the application for a stormwater permit. Witness my hand and official seal,
SEAL
ANGELA MILES
NOTARY PUBLIC
FORSYTH COUNTY,NC My commission expires /r - ?-' >o 7
w C«nmlwion Eckea// >C. ?o 7
Stormwater Fast Track ATC Application Form Page 8 of 9 Feb. 10, 2018

I. PROPERTY OWNER'S AUTHORIZATION (IF APPLICANT IS NOT THE PROPERTY OWNER)
I, (print or type name of the Property Owner)4-LAt3 �At(" 141n -�tJ certify that I
own the property identified in thispermit application, and thus give er ission to (print or type name of Applicant)
p p Y p
Meredith Will Rice Jr. with (print or type name of Applicant's
organization) Circle K Stores, Inc. to develop the project as
currently proposed. A copy of the lease agreement or pending property sales contract has been provided with the
submittal, which indicates the party responsible for the operation and maintenance of the stormwater system.
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
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6. U
Signature: "� K� 7?2 Lti L-P Date: / '2 7 2-3
I, hi��' , a Notary Public for the State of A/C. ,
County of ,th , do hereby certify that 73- 7 1-] c.-44 ac-(.d
personally appeared before me this ?? day of ,-„a.Q. , aU. .'3, and acknowledge the
due execution of the applicatign for a stormwater permit. Witness my hand and official seal,
SEAL
ANGELA MILES
NOTARY PUBLIC My commission expires /l- c, -)-Oa 7
FORSYTH COUNTY,NC
My commission Exp ss//-z`-).D A 7
Stormwater Fast Track ATC Application Form Page 8 of 9 Feb. 10,2018

J. CERTIFICATION OF CURRENT PERMITTEE (COMPLETE ONLY IF PERMIT TRANSFER IS
REQUESTED)
I, (print or type name of the Current Permittee) , am submitting
this request for a transfer of Fast Track ATC permit#SWA . With the
submission of this transfer request I am providing a copy of the most recent permit, all related documents and as-
built plans certified by my design professional in hard copy and electronic format to the Proposed
Permittee/Applicant identified in Section G of this application and to DEMLR . I further attest that this request for
a permit transfer is accurate and complete to the best of my knowledge. I assign all rights and obligations as
permittee to the proposed permittee named in Section G of this form.
Signature Date
a Notary Public for the State of
County of , do hereby certify that
personally appeared before me this day of , and acknowledge the
due execution of the application for a stormwater permit. Witness my hand and official seal,
SEAL
My commission expires
Stormwater Fast Track ATC Application Form Page 9 of 9 Feb. 10, 2018