NCS000558_OTHER_20180206

STORMWATER DIVISION CODING SHEET
M54 PERMITS
PERMIT NO.
/vC� Q
DOC TYPE
❑FINAL PERMIT
fl ANNUAL REPORT
❑ APPLICATION
❑ COMPLIANCE
CCiLLOfHER
DOC DATE
❑ a,U ! S U� � �v
YYYYMMDD

PAT MCCRORY
r r „„r.
DONALD R. VAN DEIZ VAART
S. JAY ZIMMI-RMAN
Water Resources
_NV IRON MEN I AL OUALtiY
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS000558 or NCG5 I 1 1 1
1. Facility Name: Town of Benson
11. NEW OWNERINAME INFORMATION:tECE111ED1DFN��WR
1. This request for a name change is a result of: 3AN 30 201$
a. Change in ownership of property/company Water �ECEIVResources lon
F1�.B O CD Permitting E
_X_b. Name change only
c. Other (please explain): z0l$
P=ftFILES
2. New owner's name (name to be put on permit): OWR SECTipN
Timothy W_Robbins
3. New owner's or signing official's name and title: Timothy W. Robbins
(Person legally responsible for permit)
Public Works Director
(Title)
4. Mailing address: PO Box 69 City: Benson
State: NC Zip Code: 27504 Phone: [phone]
E-mail address: trobbins(cDtownofbenson.com _.
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina' Environmental Quality 1 Water Resources
1617 Mail Service Center Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc,gov/ahout/di visions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-pennits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
I, Timothy W. Robbins , attest that this
application for a name/ownership change has been reviewed and is accurate and complete to
the best of my knowledge. I understand that if all required parks of this application are not
completed and that if all required supporting information and attachments are not included,
this application package will be returned as incomplete.
Signature: `� Date: c z_s r� d
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ 1 DWR 1 NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 712016

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
SAP 2 5 2012
LIJ
I
080121107
No person may initiate any land -disturbing activity on one or more acres as covered by the -Act before thisr:r;•I --...-�;liee
.--
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Nam e-Retail-Store #5138-00, Benson, NC
2. Location of land -disturbing activity: County Johnston City or Township Benson
Highway/Street US HWY 301 Latitude N35.616667° Longitude W78.688056°
3. Approximate date land -disturbing activity will commence: 9/30/2012
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4
6. Amount of fee enclosed: $1260.00. The Express Permitting application fee is a dual charge. The
normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express Permitting
supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee
is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are rounded up to the next
whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mark S. Goldsmith E-mail Address _mark. gold smith cewal-mart.com
Telephone [phone] Cell # Fax # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Dr. Berry Bostic _ 910-867-2452
Name Telephone Fax Number
233 Summertime Drive
Current Mailing Address
Fayetteville NC 28303
r� City State Zip
233 Summertime Drive
Current Street Address
Fayetteville NC 28303
City State Zip
10.. Deed Book No. 2136 Page No. 1249 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Wal-Mart Real Estate Business Trust
c/o Mark S. Goldsmith mark.goldsmithawal-mart.com
Name E-mail Address
2001 SE 10"' Street Mail Stop 5570 2001 SE 1 o`h Street, Mail Stop 5570
Current Mailing Address Current Street Address
Bentonville AR 72716-5570 Bentonville AR 72716-5570
City State Zip City State Zip
Telephone [phone] Fax Number(479)204-0934

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Troutman Sanders, LLP
c/o Ashley Story
Name
Two Hannover Square
434 Fayetteville Street, Suite 1900
Current Mailing Address
Ashley -story(a?tro_ utma nsa n ders. com
E-mail Address
Two Hannover Square
434 Fayetteville Street, Suite 1900
Current Street Address
Raleigh NC _27601 Raleigh _ _ NC 27601
City State Zip City State Zip
Telephone [phone] Fax Number [phone]
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address
Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Address
Individual contact person (type or print) Telephone
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath (This form must be signed by the Financially Responsible Person if an individual or his attorney -in -
fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute
instruments for the Financially Responsible Person). I agree to provide corrected information should there be
any change in the information provided herein.
Mark S. Goldsmith
Typ or print name
Signature
Senior Director of Sto_rmwater Compliance
Title or Authority T
Date
!, _ _ _er/'/ e(J.l( _ a Notary Public of the County of
State of North Carolina, hereby certify that i�c SS UD(Cl��?r _ appeared personally
before me this day and being duly sworn acknowledged that the aboveformwas executed by him.
Witness my hand and notarial seal, this��1day of
Notary
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TERRI D. HALL My commission expires
WNY Benton County
ar:= My Commission Expires
�Rr ` Sa tember 28 2015