SW8970305_HISTORICAL FILE_20170712

STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT N0.
SW_jvj?LL)6-
DOC TYPE
❑ CURRENT PERMIT
❑ APPROVED PLANS
HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
„2,12/27/%
YYYYMMDD

STAIT OF NORTR cAko 1ffj
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mde es forAc s _ e staof vt=gtM Regionaf ice is ddcatedtu wakbgpub&-MoTds Sh
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p"ic fa safeguard these mmrtis aid to cam out our day�ta-day ro ahllgeizo s. ?lease dead
e�� the��a�ggt�€d�linss sl,gthe . .
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a�Y�.ce � se�iecl�fe an appcopfine�t4 �v��tb� �e�: ��Aai�tments gill be sehe�er�
eel iQp�mand3:00 mE. ie ingt euds t4:43pa A s�MK hgat ,
2- �'aa t specify �da� poi to �evze�r b �a _name.. `Thenrrnber of �Ic,S �,a�pro�.
�.yre�e� at o�z�f�te�t�lae�tedm eve:
�. boa �a�Ce. ies of a. t�e ��en.tlze capie� zs not �. use b�tbe st�fand i peam�s.
Cast per copy is $_05 oent lyamot mar bt mde dieck muey a7rder. ff cash at to
- receptio-n desk. zee tota�iQ 5 �� Qr i�oz¢ �, e i��oiced t'or oax eou��n"sena�
d L'� � Sly mT ilk aup. Y. du �otND MY `pllea �ay�otb� taken ft�
tba ewo,- To z�mm, eer, dq&a , %adatz�, of &s�ay VAer�al illoMe a£these fifes ism
Mjsd ea=for whizh yx cau. bo �wd up to $500.00. 90 kktaf larlat. ace -
ern d in 15 ftf� review area.
�. �u aloe w�. G�zera� Stye 25h3-S I2, a $25-�0��,�oees`�ng feo tin ehargeat a�
oollected.;Enr u�.ecks �wk�pa�ie�lias beenre�sed. .
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INVOICE

Michael P. Easlev. Governor
William G. Ross .Ir.. Sccretary
North Carolina Depariment of f.nvironnncni and Nalurul RCS001CCS
Coleen Ii. Sullins Director
DiViSian of wulcr Quality
August 23, 2007
Mr. Jon T. Vincent, Owner
Gulf Stream Shopping Center
1508 Military Cutoff Road, Suite 302
Wilmington, NC 28403-5730
Subject:: Stormwater Permit No. SW8970305
Gulfstream Shopping Center
New Hanover County
Dear Mr. Vincent:
The Division of Water Quality issued a Coastal Stormwater Management Permit, Number
SVV8970305 to Gulf Stream Shopping Center, for a High Density stormwater pond to serve the
Gulf Stream Shopping Center on 7/17/1997. This permit expired on 7/17/2007.
Section .1003(h) of 15 A NCAC 2H .1000 (the storm water rules) requires that applications for
permit renewals shall be submitted 180 days prior to the expiration of a permit and must be
accompanied by a processing fee, which is currently set at $420,00. If this is still an active
project please complete and submit the enclosed renewal application in a timely manner. If this
project has not been constructed and a permit is no longer needed, please submit a request to
have the permit rescinded. If you have sold the project, or are no longer the permittee, please
provide the name, mailing address and phone number of the person or entity that is now
responsible for this permit. Enclosed is a form for change of ownership, which should be
completed and submitted if the property has changed hands.
Your permit requires that upon completion of construction and prior to operation of the
permitted treatment units a certification of completion be submitted to the Division from an
appropriate designer for the system installed. This is to certify that the permitted facility has
been Installed in accordance with the permit, the approved plans, specifications and supporting
documentation. Please include a copy of the certification with your permit renewal request and
processing fee. Enclosed is a copy of a sample certification. Also enclosed is a new Operation
and Maintenance agreement that should be completed and submitted along with your renewal
application.
You should be aware that failure to provide the Designer's Certification and the operation of a
stormwater treatment facility without a valid permit, are violations of NC General Statute 143-
215.1 and may result in appropriate enforcement action including the assessment of civil
penalties of up to $10,000 per day.
If yyou have any questions, please feel free to contact staff in the stormwater group at
910-796-7215.
Sincerely,
Ed Beck, Regional Supervisor
Surface Water Protection Section
Wilmington Regional Office
Enclosures
One
Noilhcun lilt❑
cc: Wilmington Regional Office '1hrrfrrrallf
North Carolina Division ofwuter Qualiq, 127 Cardinal Drive Extension Wilmington, NC 28405 Phone [phone]I5 Customer Service
wilminglon Regional 01' icc Internet: wtivtv,ncwalcrqua Loorg Fax [phone]-623-67=48
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2 of 3 VINCENT, JON T� 3aa
1508 Military Cutoff Rd
Wilmington, NC 28403-5730
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Atlgu5t 17, 2007
Mr. Jon T. Vincent
1508 Military Cutoff Road
Wilmington, NC 28403-5730
Subject:: Stormwater Permit No. SW8970305
Gulktl'ea111 Sho})ping Center
New I lanovel, ount),
Dear Mr. Vincent:
Michael F. Easley, Governor
William G, Ross Jr„ Secrciary
North Carolina Department ol'I:nvironmem and Natural Resources
Colecn 11. Sullins Director
Division of Water Quality
Please provide us With your suite number at 1508 Military Cutoff Road. We have important mail to
send you regarding your Stormwater Permit No. SW8970305.
Our fax number is 910 350-2004 or you can contact me at 910 796-7271 Thank you.
Sincerely yours,
Fliza th D. 1-Iickmon
ID1-I/led
S: 1WQSIStormwater\Inspect\Pats inspections\SW8970305
iV&'OtCarolinit
JN1,1111PRllif
North Carolina Division of Water Quality 127 Cardinal [hive Extension Wilmington, NC 29,105 Phone [phone] i5 Cusmsmer Service
Wilmington Regional office , Internet: Fax [phone]i
An Equal Opportunity/Affirmative Action Employer— 5C% RecycledM% Post Consumer Paper

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P. 01
TRANSACTION REPORT
AUG-17-2007 FRI
11,40 AM
FOR: NCDENR
9103502004
SEND
DATE START RECEIVER
TX TIME PAGES TYPE
NOTE
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AUG-17 11:39 AM 92560522
22" 2 FAX TX
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370
TOTAL
22S PAGES: 2
G� A
NCDENR
North Carolina Department of Environment and Natural Resources
Wilmington Regional mce
(91 D) 795-7215
Michael F Easley, Governor �Vil4iar�4 G. Ross Jr., Secretary
FAX COVER SHEET'
Dater ' # a n es
P d
rn.:
556-osaa `J
From:
Division
FA.X #. 910-350-2004
2�51 Fiiil. 9�0 Z500
727 Cardinal Drive Exi ,'Wiiminglart, Norlh Carolina 231405-3845 � Tine- 5i0 796.7

NCDENR
North Carolina DepartLment of Environment and Natura
Wilmington Regional Office
[phone]
kkhael F. Easley, Governor
FAX COVER SHEET
Date:--� _
To: T. V'-a
Co":
Fax:' 9/0 1�56- o sa O
# pages
I
Resources
Wilharn & Ross Jr., Secretary
From: i ►L��t
Division
FAN #: 910-350-2004
TTI—cj;dinal Drive i_/l -Wdming Ion, Norlh C.arrM3 284u5-3845 - Phone; 9iC-796-7 "I 15 1 FAX, 910-350-�004

Michael P. Easley, Governor
William G. Ross Sr., Secretary
North Carolina Department of Fnviranmenl and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
May 22, 2007
Mr. Jon T. Vincent, Owner
5315 South College Rd.
Wilmington, NC 28412
Subject:: Stormwater Permit No. SW8970305
Gulfstream Shopping Center
New Hanover County
Dear Mr. Vincent:
The Division of Water Quality issued a Coastal Stormwater Management Permit, Number SW8970305
to Gulf Stream Shopping Center, for a High Density stormwater pond to serve the Gulf Stream
Shopping Center on 7/17/1997. This permit will expire on 7/17/2007. Section .1003(h) of 15 A NCAC
2H .1000 (the stormwater rules) requires that applications for permit renewals shall be submitted 180
days prior to the expiration of a permit and must be accompanied by a processing fee, which is
currently set at $420,00. If this is still an active project please complete and submit the enclosed
renewal application in a timely manner. If this project has not been constructed and a permit is no
longer needed, please submit a request to have the permit rescinded. If you have sold the project, or
are no longer the permittee, please provide the name, mailing address and phone number of the
person or entity that is now responsible for this permit. Enclosed is a form for change of ownership,
which should be completed and submitted if the property has changed hands.
Your permit requires that upon completion of construction and prior to operation of the permitted
treatment units a certification of completion be submitted to the Division from an appropriate designer
for the system installed. This is to certify that the permitted facility has been installed in accordance with
the permit, the approved plans, specifications and supporting documentation. Please include a copy of
the certification with your permit renewal request and processing fee. Enclosed is a copy of a sample
certification. Also enclosed is a new Operation and Maintenance agreement that should be completed
and submitted along with your renewal application.
You should be aware that failure to provide the Designer's Certification and the operation of a
stormwater treatment facility without a valid permit, are violations of NC General Statute 143-215.1 and
may result in appropriate enforcement action including the assessment of civil penalties of up to
$10,000 per day.
If you have any questions, please feel free to contact staff in the stormwater group at 910-798-7215,
Sine ely,
Ed Beck, Regional Supervisor
Surface Water Protection Section
Wilmington Regional Office
Enclosures
cc: Wilmington Regional Office
North Carolina Division of Water Quality Internet: wa'w.ne+vain' unfit .or One
127 Cardinal drive Fxtension Phone [phone] North Carolina
Wilminglon, NC 28403 Fax [phone] Vatu all y
An Equal Opportunity/Affirmative Action Employer — 50% Recycled110% Post Consumer Paper `/

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127 Cardinal Drive Extension
Y Wilmington, NC 28403
f 02 1A $ 00.58cl •
0004337146 MAY24 2007
• [NAILED FROM ZIP CODE 28405
Mr. Jon T. Vincent, Owner f j
5315 South College Rd. ��p
Wilmington, NC 28412 �GGc.C� C�V3403)�� 0
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TRIPP ENGINEERING, P.C.
507 Chestnut Street
Wilmington, North Carolina 28401
Phone: [phone] • Fax: [phone]
NCDEHNR
Division of Environmental Management
Water Quality Section
127 Cardinal Drive r
Wilmington, NC 28405-3845 ,-
Attn: Ms. Linda Lewis
Re: Walmart West
Wilmington, NC
Revised Stormwater Management Plan
SW8 970305
TE No. 9697
Dear Linda:
CEIV E
J U L 0 2 1997
July 1, 1997
Enclosed please find two sets of revised plans and
calculations. As per your June 26, 1997 correspondence we offer
the following with respect to your comments:
1) We enclose the permit application with Mr. Vincent's
title.
2) We enclose the revised Site Plan and details showing the
vegetated shelf between the permanent pool and the
storage pool.
3) We enclose the revised Site Plan indicating no wetlands
on site.
4) We enclose the revised details and calculations
indicating a 1" diameter orifice. This orifice was
calculated for both the two day and five day drawdown and
a 1" diameter orifice falls between two and five days.
Please review for approval and contact me with any questions
or comments. Thank you.
Sincerely,
S. Lance Strawn

wHALE=
•
Dennis O'Bannon
124 N. Cardinal Dr., Wilmington, NC 28405
[phone] • [phone] Fax
Pager [phone] • Mobile [phone]
i

State of North Carolina
Department of Environment, Health, and Natural Resources
Wilmington Regional Office
James B. Hunt, Jr. Division of Water Quality Jonathan B. Howes
Governor Water Quality Section Secretary
June 26, 1997
Mr. Phil Tripp, P.E.
Tripp Engineering
507 Chestnut_ Street
Wilmington, NC 28401
Subject: ACKNOWLEDGEMENT OF RECEIPT AND
REQUEST FOR ADDITIONAL INFORMATION
Stormwater Project No. SW8 970305
WalMart West
New Hanover County
Dear Mr. Tripp:
The Wilmington Regional Office received previously requested information for the Stormwater
Management Permit Application for WalMart West on June 9, 1997. A preliminary review of that
information has determined that the application is not complete. The following information is needed to
continue the stormwater review:
Z1. Please add Mr. Vincent's title to the permit application. Refer to NCAC 2H.1003 (e) for
information on who may sign the permit application if Mr. Vincent is not an owner, partner,
President or Vice President.
L/"2. Relocate the 6:1 vegetated shelf such that it is not continually under water. The best place is
just above the permanent pool, and below the storage pool.
;j 3. Provide 2 copies of the most recent drawings. Only 1 set of Revision 2 plans was received on
June 19, 1997.
4. Delineate all wetlands 'on site, or note on the plans that none exist.
5. The orifice size was rounded up, resulting in a drawdown of less than 2 days. Please
T\ remember that when calculating the 2 day drawdown, the'orifice size calculated is already as
large as it can be. Rounding up only decreases the drawdown time to below 2 days. Please
calculate both the 2 day and the 5 day sizes and choose a size in between.
127 Cardinal Drive Extension, Wilmington, N.C. 28405-3845 • Telephone [phone] • Fax [phone]
An Equal Opportunity Affirmative Action Employer.

Mr. Tripp
June 26, 1997
Storrnwater Project No. SW8 970305
Please note that this request for additional information is in response to a preliminary review. The
requested information should be received by this Office prior to July 26, 1997, or the application will be
returned as incomplete. The return of a project will necessitate resubmittal of all required items, including
the application fee.
If you have any questions concerning this matter please feel free to call me at [phone].
Sincerely,
w
Ms. Linda Lewis
Environmental Engineer
RSSlarl: - S:IWQSISTORMWATIADDINF01970305.JUN
cc: Linda Lewis
Central Files
127 Cardinal Drive Extension, Wilmington, N.C. 28405-3845 • Telephone [phone]' Fax [phone]
An Equal Opportunity AT mative Action Employer

TRIPP ENGINEERING P.C.
507 Chestnut Street
Wilmington, North Carolina 28401
Phone: [phone] • Fax: [phone] RECE'FG�'
JUN 0 91997
June 5, 1997
NCDEHNR
Division of Environmental Management
Water Quality Section
127 Cardinal Drive
Wilmington, NC 28405-3845
Attn: Ms. Linda Lewis
Re: Wal Mart West
TE No. 9697
Dear Linda:
Enclosed please find two (2) sets of plans, one signed
application form, and a check to cover the application fee.
Please review for approval and contact us with any questions
or comments. Thank you.
S ei e 1 yj
P i G. TripFP.E.
PGT/j s
Enc.

r
° - TRipp ENGINEERING, P.C.
r 507 Chestnut Street:��7,��D
Wilmington, North Carolina 28401
Phone: [phone] • Fax: [phone] JUN 19 1997
1BY:3-JQ3Q-5-;1
New Hanover County
Engineering Department
414 Chestnut Street
Wilmington, NC 28405-4045
Attn: Ms. Beth Easley
Re: Walmart West
Wilmington, NC
Revised Erosion Control Plan
TE No. 9697
Dear Beth:
June 16, 1997
We are in receipt of your June 6, 1997 comments and offer the
following:
1) We enclose drainage calculations and energy dissipater
dimensions for new pipe system and pond.
2) We enclose Revised Site Plan & Detail sheet showing
construction entrances.
3) We have forwarded a plan to Linda Lewis.
4) we enclose front swale calculations and revised detail
sheet showing front swale detail.
5) We enclose revised site plan showing construction
entrance between Taco Bell and site.
Please review for approval and contact us with questions or
comments. Thank you.
Sincerely,
S. Lance Strawn

TRIPP ENGINEERING P.C.
507 Chestnut Street
Wilmington, North Catalina 28401
Phone: [phone] • Fax: [phone]
March 14, 1997
MAR
NCDEHNR
Division of Environmental Management 9 99%
Water Quality Section 70 0
127 Cardinal Drive
Wilmington, NC 28405-3845
Attn: Ms. Linda Lewis
Re: Wal-Mart West
TE No. 9697
Dear Linda:
we are writing in response to your March 6, 1997
correspondence. Enclosed are two sets of the proposed site
plan. As we discussed by phone, this project will be
included as part of a larger stormwater system being
designed by Dawson Engineering. We will be submitting as an
offsite contribution at a later date and ask that you please
put this project on an administrative hold. No impervious
will be placed on this tract prior to submittal of final
plans, application, fees, etc. to your office.
Please contact us with any questions or comments. Thank you.
S i1PN er ly,
Phillip G. Tri P.E.
Enclosures
cc: Jon Vincent

LSy STATEa
I
State of North Carolina
Department of Environment, Health, and Natural Resources
Wilmington Regional Office
James B. Hunt, Jr. Division of Water Quality Jonathan B. Howes
Governor Water Quality Section Secretary
March 14, 1997
Mr. Phil Tripp, P.E.
Tripp Engineering
507 Chestnut Street
Wilmington, NC 28401
Subject: ACKNOWLEDGEMENT OF RECEIPT AND
REQUEST FOR ADDITIONAL INFORMATION
Stormwater Project No. SW8 970305
Gulfstream Shopping Center
New Hanover County
Dear Mr. Tripp:
The Wilmington Regional Office received a Stormwater Management Permit Application for
Gulfstream Shopping Center on March 4, 1997. A preliminary review of that. information has determined
that the application is not complete. The following information is needed to continue the stormwater review:
1. A $225.00 application fee for an off -site system.
2. A completed permit application.
3. Calculations of the built -upon area.
4. This project has been allotted 80%, or 65,837 square feet of built -upon area.
5. Delineate all wetlands on site, or note on the plans that none exist.
6. The method of collection appears to be in pavement swales to an earthen roadside swale. That
swale is not shown on the 970215 project. .
127 Cardinal Drive Extension, Wilmington, N.C. 28405-3945 • Telephone [phone] • Fax [phone]
An Equal Opportunity Affirmative Action Employer
State of North Carolina
Department of Environment, Health, and Natural Resources
Wilmington Regional Office
James B. Hunt, Jr. Division of Water Quality Jonathan B. Howes
Governor Water Quality Section Secretary
March 14, 1997
Mr. Phil Tripp, P.E.
Tripp Engineering
507 Chestnut Street
Wilmington, NC 28401
Subject: ACKNOWLEDGEMENT OF RECEIPT AND
REQUEST FOR ADDITIONAL INFORMATION
Stormwater Project No. SW8 970305
Gulfstream Shopping Center
New Hanover County
Dear Mr. Tripp:
The Wilmington Regional Office received a Stormwater Management Permit Application for
Gulfstream Shopping Center on March 4, 1997. A preliminary review of that. information has determined
that the application is not complete. The following information is needed to continue the stormwater review:
1. A $225.00 application fee for an off -site system.
2. A completed permit application.
3. Calculations of the built -upon area.
4. This project has been allotted 80%, or 65,837 square feet of built -upon area.
5. Delineate all wetlands on site, or note on the plans that none exist.
6. The method of collection appears to be in pavement swales to an earthen roadside swale. That
swale is not shown on the 970215 project. .
127 Cardinal Drive Extension, Wilmington, N.C. 28405-3945 • Telephone [phone] • Fax [phone]
An Equal Opportunity Affirmative Action Employer

Mr. Tripp
March 14, 1997
Stormwater Project No. SW8 970305
7. The 970215 project must be complete and the Engineer's Certification in this Office prior to
issuing a permit for this construction. The work of clearing and grading under an approved
Erosion Control Plan may commence prior to receipt of the Stormwater permit. This project
will be placed on hold pending 970215 completion. You may elect to construct a temporary
detention pond if the developer cannot wait.
Please note that this request for additional information is in response to a preliminary review. The
requested information should be received by this Office prior to April 14, 1997, or the application will be
returned as incomplete. The return of a project will necessitate resubmittal of all required items, including
the application fee.
If you have any questions concerning this matter please feel free to call me at [phone].
Sincerely,
Ms. Linda Lewis
Environmental Engineer
RSSIarl: S:IWQSISTORMWATIADDINF01970305.MAR
cc: Linda Lewis
Central Files
2

Date
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Design Sheet
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507 Chestnut Street
0 Wilmington, North Carolina 28401
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Do not use for Intema6onai Mail See rsve�e
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Street & Num
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state, & zla
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■Complgle items 1 and/or2 foradditional sarvices.
r/t ■Complete items 3, 4a, and 4b.
■ Print your name and address on the reverse of this form so that we can return this
card to you.
} •Attach this forth to the front of the mailpiece, or on the back if space does not
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o • Write'Retum Receipt Requested' on the matlpiece below the article number.
■The Return Receipt will show to whom the article was delivered and the dale
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p 5. Received By: (Print Name)
g s. Signat� . (dd sses or Agent)
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• Print your name, address, and ZIP Code in this box •
r � _
VA"ONMiR6i, HEALTH & NATURAL RESouRCES 727 CARDINAL DRIVE EXTENSION
WILMINGTON, NG 28405,WS

� SUhTF o
State of North Carolina
Department of Environment, Health, and Natural Resources
Wilmington Regional Office
James B. Hunt, Jr. Division of Water Quality Jonathan B. Howes
Governor Water Quality Section Secretary
March 6, 1997
CERTIFIED MAIL P 110 495 001
RETURN RECEIPT REQUESTED
Mr. John Vincent, Manager
Gulfstream Shopping Center Properties, LLC
5315 S. College Road
Wilmington, North Carolina 28412
Subject: REQUEST FOR STORMWATER I%IA.NAGEMENT
PERMIT APPLICATION
WalMart West
Stormwater Project No. SW8 970305
New Hanover County
Dear Mr. Vincent:
On March 4, 1997, the Wilmington Regional Office received a copy of the Sedimentation Erosion Control Permit
Application for WalMart. The North Carolina Administrative Code requires any project that must receive either a
Sedimentation and Erosion Control Plan permit and/or a CAMA major permit to apply for and receive a Stormwater
Management Permit by the Division of Water Quality. Any construction on the subject site, prior to receipt of the required
permit, will constitute a violation of 15A NCAC 2H.1000 and may result in appropriate enforcement action by this Office.
Either a Stormwater Permit Application Package including 2 sets of plans, completed application form, fee, and
supporting documentation, or a written response regarding the status of this project and the expected submittal date must
be received in this Office no later than April 4, 1997, or the subject project file will be closed and construction may
experience a subsequent delay. If you have any questions, please call me at (910)-395-3900.
Sincerely,
Linda Lewis
Environmental Engineer
RSSlarl: S:IWQSISTORMWATISTORMSUB1970305.MAR
cc: Tony Roberts, New Hanover County Inspections
EriFa- Lewis
Central Files
127 Cardinal Drive Extension, Wilmington, N.C. 28405-3845 • Telephone [phone] • Fax [phone]
An Equal Opportunity Affirmative Action Employer

NEW HANOVER COUNTY
OFFICE OF THE COUNTY MANAGER
320 CHESTNUT STREET, ROOM 502
WILNMiGTON, NORTH C4ROLINA 28401-4093
TELEPHONE [phone]
FAX [phone]
I �9@199wa
MAR 0 4 1997
jjjj;�Wlaio S
MEMORANDUM
TO: LINDA LEWIS
DEM
FROM: BETH £ASLEY
EROSION CONTROL SPECIALIST
RE: SEDIMENTATION AND EROSION CONTROL PLAN
6- P it - `) r7 WC LQ M-O" -t- w eQ
Please review the attached plan.
A7.i FN oTfELL
County Manager
AIM REW S. ATIQP75oN CPA
Deputy County Manage
DAVM F. WF,AVr-R
Assistant County Manage
414 Chestnut Street, Room 101
Telephone [phone]
Fax [phone]
If you have any questions, please contact this office.
BE/aj
Attachment

ENGINEERING &FACIUTES APPLICATION FOR PERMIT FOR ��
five LAMMI)ISTURBING ACTIVITYto N m er
UNDER THE CONDITIONS SET -FORTH BY MAR 0 4 �9��Ift S
* Tl•IE NEW HANOVER COUNTY ee Pa
° Y SOIL EROSION AND SEDIMENTATION CONTROL ORDINANCE
.. Vat
Gul.fst ream Shopping Center
Applicant: -Pv- ex: t i e-e�,.—LL o _ ... - - - Applicant's Agent: Same
Address:— - I Road Address:
Wilmington, NC 28412
Telephone Number: 910/799--6901 Telephone Number:
Total Acres of Land Disturbance: 3, o AC Purpose of Development: Commercial
Location and Description of Land Disturbance:
Monkey Junction, next to Taco Hell
Land owner(s) of Record
STATEMENT OF FINANCIAL RESPONSIBILITY
Person or firm(s) Cnancially responsible for the
land disturbing activity. If not a North Carolina
resident you must have a N.C. agent (List Below)
Gulfabream Shopping Center Gulfstream Shopping Center
Name:,p_Kj4Lex_tt ps, TaLC - - Name:
Address:- trot,-1 eg e- Re���? Address: 5 3� S _ Goy l ege—Read
Telephone Number: 91 n /:799 .6901 Telephone Number:
Location of deed(s) or instrument(s): County, New Honoyrer, _ Book Page
The above information is trua and correct to the best of my knowledge and belief and was provided by me while under oath.
(This Corm must be signed by the financially responsible person if an Wdividual and by an officer, director, partner, attomey-trl-
fact, or other person of authority to execute Instruments for the financially fesponsiblef arson If not an Individual)] agree to
provide corrected Information should there be any change in the information provided kerein.
Date: l 1 -7 Name (Tye
Title: '/ k e Signature:
t14116 A
a Notary Public of the County of l ) �-- L7 `tate of North
Carolina, hereby ocrtify, that;: 1 _ jsJl'`,E :1ti ; 1 appeared personally before me this day and be-
ing duly swum ackrxviviedged that the above form was executed by him.
Witness my had and notaflal seal,
Seal . ' _ 1
My commission
L day of 119
!r: