SW7131013_CURRENT PERMIT_20210709

I
STORMWATER DIVISION CODING SHEET
POST -CONSTRUCTION PERMITS
PERMIT NO.
SW 7`. 3l
DOC TYPE
[ CURRENT PERMIT
❑ APPROVED PLANS
❑ HISTORICAL FILE
❑ COMPLIANCE EVALUATION INSPECTION
DOC DATE
�r
YYYYMMDD

Iva A,O
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
BRIAN WRENN
Director
1421 Valencia Street, LLC
Attention: Diane Litke
7403 Highline Court
Missoula, MT 59808
NORTH CAROLINA
Environmental Quality
July 9, 2021
Subject: Stormwater Permit No. SW7131013 Renewal/Ownership Transfer
CVS Pharmacy Store #7344
High Density Project
Havelock, NC, Craven County
Dear Ms. Litke:
The Washington Regional Office received a Stormwater Management Permit
Application for renewal and transfer of ownership of the subject permit on June 3, 2021.
Staff review of the applications has determined that the permit can be reissued. We are
forwarding Permit No. SW7131013 dated July 9, 2021, for the continued operation of a
constructed wetland stormwater treatment system.
This permit, upon its effective date, will replace all previous State Stormwater permits for
this project. This permit shall be effective from the date of issuance until July 8, 2029 and
shall be subject to the conditions and limitations as specified therein and does not
supercede any other agency permit that may be required. Please pay special attention to
the Operation and Maintenance requirements in this permit. Failure to establish an
adequate system for operation and maintenance of the stormwater management system
will result in future compliance problems.
If any parts, requirements, or limitations contained in this permit are unacceptable, you
have the right to request an adjudicatory hearing upon written request within thirty (30)
days following receipt of this permit. This request must be in the form of a written petition,
conforming to Chapter 150E of the North Carolina General Statutes, and filed with the
Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714,
Unless such demands are made this permit shall be final and binding.
If you have any questions, or need additional information concerning this matter, please
contact me at [phone].
Sincerely,
/J ,-{ /G- ,��iC' 1'
Roger K. Thorpe
Environmental Engineer
North Carolina Department of Environmental Quality Division of Energy, Mineral and Land Resources
2r Washington Re9lonal Office 1943 Washington Sguare,Mail l Washington. North Carolina 27889
252.946.64J1

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
STATE STORMWATER MANAGEMENT PERMIT
HIGH DENSITY DEVELOPMENT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North
Carolina as amended, and other applicable Laws, Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
1424 Valencia Street, LLC
CVS Pharmacy Store # 7344
Located at 103 Catawba Road, Havelock, NC
Craven County
FOR THE
construction, operation and maintenance of a constructed wetlands in compliance with
the provisions of 15A NCAC 2H .1000 (hereafter referred to as the "stormwaterrules')
and the approved stormwater management plans and specifications and other
supporting data as attached and on file with and approved by the Division of Energy,
Mineral, and Land Resources (Division) and considered a part of this permit.
This permit shall be effective from the date of issuance until July 8, 2029, and shall
be subject to the following specified conditions and limitations:
I. DESIGN STANDARDS
1. This permit is effective only with respect to the nature and volume of stormwater
described in the application and other supporting data.
2. This stormwater system has been approved for the management of stormwater
runoff as described in Section 1.7 of this permit. The stormwater controls have
been designed to handle the runoff from 18,250 square feet of impervious area.
3. The tract will be limited to the amount of built -upon area indicated in Section I. of
this permit, and per approved plans.
All stormwater collection and treatment systems must be located in either
dedicated common areas or recorded easements. The final plats for the project
will be recorded showing all such required easements, in accordance with the
approved plans.
� �R North Carolina Department of Environmental Qualify I Division of Energy, Mine:zl and Wnd Resources
J/ Washington Regional Office 1 9J3 Washington Square Mall 1 Washington, North Carolina ?7884

The runoff from all built -upon area within the permitted drainage area of this
project must be directed into the permitted stormwater control system.
The built -upon areas associated with this project shall be located at least 50 feet
landward of all perennial and intermittent surface waters.
The following design criteria have been provided in the constructed wetland and
must be maintained at design condition:
a. Drainage Area, ft2:
b. Total Impervious Surfaces, ft2:
C. Design Storm, inches:
d. Permanent Pool (PP)Elevation, FMSL:
e. Shallow Water (PP) Surface Area, ft2:
f. Temporary Pool (TP) Elevation, FMSL:
g. Shallow Land (TP) Surface Area, ft2:
h. Required Storage Volume, ft2:
i. Permitted Storage Volume, ft3:
j. Controlling Orifice:
k. Permitted Forebay Surface Area, ft2:
I. Receiving Stream/River Basin: LIT to
M. Stream Index Number:
n. Classification of Water Body:
II. SCHEDULE OF COMPLIANCE
28,750
18,250
1.50
24.00
1,263
25.00
1,215
2,233
3,305
1.00"0 pipe
386
Tucker Creek/ Neuse Basin
27-112-6
"SC; Sw; NSW"
The stormwater management system shall be constructed in its entirety,
vegetated and operational for its intended use prior to the construction of any
built -upon surface.
During construction, erosion shall be kept to a minimum and any eroded areas of
the system will be repaired immediately.
The permittee shall at all time provide the operation and maintenance necessary
to assure the permitted stormwater system functions at optimum efficiency. The
approved Operation and Maintenance Plan must be followed in its entirety and
maintenance must occur at the scheduled intervals including, but not limited to:
a. Semiannual scheduled inspections (every 6 months).
b. Sediment removal.
C. Mowing and re -vegetation of slopes and the vegetated filter strip.
d. Immediate repair of eroded areas.
e. Maintenance of all slopes in accordance with approved plans and
specifications.
f. Debris removal and unclogging of outlet structure, orifice device, level
spreader, filter strip, catch basins and piping.
a. Access to the outlet structure must be available at all times.
4. Records of maintenance activities must be kept for each permitted SCM. The
records will indicate the date, activity, name of person performing the work and
what actions were taken.
® North Carolina Department of Environmental Quality I Division of Energy. Mineral and Land Resources
e fJ:- Washington Regional Office 1 943 Washington Square Mall I Washington. North Carolina 27889
m „ 252.94&o481

Access to the stormwater facilities shall be maintained via appropriate
easements at all times.
6. Decorative spray fountains will not be allowed in the stormwater treatment
system.
7. The facilities shall be constructed as shown on the approved plans. This permit
shall become void unless the facilities are constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other
supporting data.
8. Upon completion of construction, prior to issuance of a Certificate of Occupancy,
and prior to operation of this permitted facility, a certification must be received
from an appropriate designer for the system installed certifying that the permitted
facility has been installed in accordance with this permit, the approved plans and
specifications, and other supporting documentation. Any deviations from the
approved plans and specifications must be noted on the Certification. A .
modification may be required for those deviations.
9. If the stormwater system was used as an Erosion Control device, it must be
restored to design condition prior to operation as a stormwater treatment device,
and prior to occupancy of the facility.
10. The permittee shall submit to the Director and shall have received approval for
revised plans, specifications, and calculations prior to construction, for any
modification to the approved plans, including, but not limited to, those listed
below:
a. Any revision to any item shown on the approved plans, including the
stormwater management measures, built -upon area, details, etc.
b. Project name change.
C. Transfer of ownership.
d. Redesign or addition to the approved amount of built -upon area or to the
drainage area.
e. Further subdivision, acquisition, lease or sale of all or part of the project
area. The project area is defined as all property owned by the permittee,
for which Sedimentation and Erosion Control Plan approval or a CAMA
Major permit was sought.
f. Filling in, altering, or piping of any vegetative conveyance shown on the
approved plan.
11. The Director may notify the permittee when the permitted site does not meet one
or more of the minimum requirements of the permit. Within the time frame
specified in the notice, the permittee shall submit a written time schedule to the
Director for modifying the site to meet minimum requirements. The permittee
shall provide copies of revised plans and certification in writing to the Director
that the changes have been made.
12. The permittee shall submit final site layout and grading plans for any permitted
future areas shown on the approved plans, prior to construction.
13. A copy of the approved plans and specifications shall be maintained on file by
the Permittee at all times.
North Carolina Department of Envh onmen[al Quality ; Division of Energy. Mineral and Land Resources
Washington Regional Office I 04'3Washingron Square Stall I Washington. North Carolina 77884
i +a �++V_ 25LAd6.od87

III. GENERAL CONDITIONS
This permit is not transferable except after notice to and approval by the Director.
In the event of a change of ownership, or a name change, the permittee must
submit a completed Name/Ownership Change form, to the Division of Energy,
Mineral, and Land Resources, signed by both parties, and accompanied by
supporting documentation as listed on page 2 of the form. The project must be in
good standing with the Division. The approval of this request will be considered
on its merits and may or may not be approved.
2. The permittee is responsible for compliance with all permit conditions until such
time as the Division approves the transfer request.
3. Failure to abide by the conditions and limitations contained in this permit may
subject the Permittee to enforcement action by the Division of Energy, Mineral,
and Land Resources, in accordance with North Carolina General Statute 143-
215.6A to 143-215.6C.
4. The issuance of this permit does not preclude the Permittee from complying with
any and all statutes, rules, regulations, or ordinances, which may be imposed by
other government agencies (local, state, and federal) having jurisdiction.
5. In the event that the facilities fail to perform satisfactorily, including the creation of
nuisance conditions, the Permittee shall take immediate corrective action,
including those'as may be required by this Division, such as the construction of
additional or replacement stormwater management systems.
6. The permittee grants DEQ Staff permission to enter the property during normal
business hours for the purpose of inspecting all components of the permitted
stormwater management facility.
The permit issued shall continue in force and effect until revoked or terminated.
The permit may be modified, revoked and reissued or terminated for cause. The
filing of a request for a permit modification, revocation and re -issuance or
termination does not stay any permit condition.
Unless specified elsewhere, permanent seeding requirements for the stormwater
control must follow the guidelines established in the North Carolina Erosion and
Sediment Control Planning and Design Manual.
9. Approved plans and specifications for this project are incorporated by reference
and are enforceable parts of the permit.
10. The issuance of this permit does not prohibit the Director from reopening and
modifying the permit, revoking and reissuing the permit, or terminating the permit
as allowed by the laws, rules and regulations contained in Title 15A NCAC
21-1.1000, and NCGS 143-215.1 et.al.
11. The permittee shall notify the Division of any name, ownership or mailing address
changes at least 30 days prior to making such changes.
North Carolina Department of Envhanmental Quality Uivisian or Energy. Mineral and Land Resources
,./ Washington Regional Office I o 13 Washingron Square.Mall i Washington. North Carolina 27884
�a� / 252946b481

12. This permit shall be effective from the date of issuance until July 8, 2029.
Application for permit renewal shall be submitted 180 days prior to the expiration
date of this permit and must be accompanied by the processing fee.
Permit issued this the 9 th day of July 2021.
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
----� � For
Brian Wrenn, Director
Division of Energy, Mineral and Land Resources
By Authority of the Environmental Management Commission
Permit Number SW7131013
Qp North Carolina Deem tment of Environmental Qualitv I Division of Energy. Mineral and Land Resources
J/ Washington Regional Office I q33 Washington Square Mall Washington North Carolina 273A4
a :ry ,.n. me•� /"�O 252o,46b481

DEMLR USE ONLY
Date Received
Fee Paid
Permit Number
'21
-0S',o�
l
1310 1'
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER:
PERMIT TRANSFER APPLICATION FORM
Pursuant to 15A NCAC 02H.1045 and otherapplicable 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: http://deo.nc.00v/contact/reoional-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: SW7131013
2. Project name: CVS Pharmacy Store #7344-103 Catawba Road Havelock NC
Is this an updated project name from the current permit? ❑ Yes ❑ No
3. Reason for the permit transfer request:
Current Permit expires 11/22/2021 and new ownership since last permit application
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)
❑ 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:
❑ 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

�nac_kev9-2ts awl,c

C. SUBMITTAL REQUIREMENTS
Please mark Y'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 rive dollars ($505.00) per G.S. 143-215.3D(e)(2).
2. Two hard copies (with original signatures) and one electronic copy of this completed form and the
required items.
Y 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.
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.
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.
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.
T 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.
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.
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.
10. A copy of the lease agreement if the proposed permittee is the lessee.
11. A copy of the pending sales agreement if the proposed permittee is the purchaser.
12. A copy of the development agreement if the proposed permittee is the developer.
Storrnwater 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:
2. Signing Official's Name:
3. Signing Official's Title:
4. Mailing Address:
City:
5. Street Address:
City:
6. Phone: (� _
State:
I, , 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)
❑ the most recent permit;
❑ the designer's certification for each SCM;
❑ any recorded deed restrictions, covenants, common areas, drainage easements or plats;
❑ the approved plans and/or approved as -built plans;
❑ the approved operation and maintenance agreement;
❑ past maintenance records from the previous permittee (where required);
❑ a copy of the most recent inspection report;
I 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 the proposed permittee named below. I understand that this request to transfer the
permit may not be approved by the DEMLR unless and until the facility is in compliance with the permit.
Signature:
that
this the
day of
County of
execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature:
My commission expires
Stormwater Permit Transfer Application Form
Page 4 of 7
Date:
a Notary Public for the State of
do hereby certify
personally appeared before me
20 , and acknowledge the due
April 27, 2018

E. PROPOSED PERMITTEE INFORMATION
The proposed permittee is the:
® 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):
® Corporation, LLC, Partnership, Municipality name: 1424 Valencia Street. LLC
❑ HOA / POA / UOA name:
❑ Sole Proprietor
3. Proposed permittee contact information:
Please be sure to provide Email.
a. Signing Official's Name: Diane Litke
b. Signing Official's Title: Member
c. Mailing Address: 7403 Highline Court
City: Missoula State: MT ZIP: 59808
d. Street Address: same as above
City: State: ZIP:
e. Phone: (44� 327-2702 Email: dlitke415(Daol.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:
b. Contact Name:
c. Mailing Address:
Title:
d. City: State: ZIP:
e. Phone: U Email:
Stormwater Permit Transfer Application Form Page 5 of 7 April 27, 2018

F. PROPOSED PERMITTEE CERTIFICATION
I, Diane Litke , 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):
® the most recent permit;
❑ the designer's certification for each SCM;
❑ any recorded deed restrictions, covenants, common areas, drainage easements or.plats;
❑ the approved plans and/or approved as -built plans;
❑ the approved operation and maintenance agreement;
❑ past maintenance records from the previous permittee (where required);
❑ 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 requirements listed in the permit and in the operation and maintenance agreement.
Signature: Date: May 28, 2021
I, LAVY.tA & f lSy Wr a Notary Public for the State
, of �ry'}ZP.Vw ,
County of L Arm do hereby certify that DAM U'He-&
aroagad
FISHER he day of 1� 20 a{ and
ee'
egbeaAlNQ,m@4tlpfh&f t forgoing instrument. Witness my hand and official seal,
State of Montana
Residing at Poison Montana
alpiy Commission Expires
January 01, 2023
Notary Signature 2k&
My commission expires 01-Di - (MO
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:
Signing Official's Printed Name:
Signing Official's Title:
Mailing Address:
City: State: ZIP:
Phone:(—)
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 teasing 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 tease 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:
a Notary Public for the State of
County of , do hereby certify that
personally appeared before me this the day of
, 20 , and acknowledge the due execution of the forgoing instrument. Witness
my hand and official seal,
(Notary Seal)
Notary Sig
My commission expires
Stormwater Permit Transfer Application Form Page 7 of 7 April 27, 2018

DEMLR USE ONLY
LH�Date Received Fee Paid Permit Number
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER:
PERMIT RENEWAL APPLICATION FORM
In accordance with 15A NCAC 2H.1045(3), the current permit holder shall renew their high density permit 180 days
prior to its expiration. Renewed permits are valid for a period of 8 years per Session Law 2011-398 (SB 781)
Section 60. (c). This application form is for permit renewals only.
A. PROJECT INFORMATION
1. State Stormwater Permit Number:
2. Project name: CVS Pharmacy Store #7344-103 Catawba Road, Havelock, NC
3. Project street address: 103 Catawba Road
City:
County: Craven ZIP:
4. What, if any, changes have been made to the project as permitted?
If the project has changed from the original approved plans, please complete SWU-101 for a Major
Modification or Minor Modification Application form available at: hffps://deg.nc.gov/about/divisions/energv-
minera I-land-resources/energy-mineral-la nd-rules/stormwater-program/post-construction.
B. PERMITTEE INFORMATION
If changes to the permittee or project name have been made, please complete either the Permit Update form
or the Permit Transfer form available at., https://deg.ne.goy/about/divisions/enerqv-mineral-land-
resources/energy-mineral-land-rules/stormwater-program/post-construction. State Stormwater Permits do not
automatically transfer with the sale of the property.
1. Current Permit Holder's Company Name/Organization: 1424 Valencia Street, LLC
2. Signing Official's Name: Diane Litke
3. Signing Official's Title: Sole Member
4. Mailing Address: 7403 Highline Court
City: Missoula
5. Street Address: same as above
City: State
6. Phone: (4_Q6J 327-2702 Email: dlitke415(Waol.com
MT —ZIP: 59808
ZIP:
Stormwater Permit Renewal Form Page 1 of 3 May 11, 2018

C. 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 applications 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:
DL 1. A permit application processing fee of $505.00 payable to NCDEQ.
DL 2. One original signed hard copy and one electronic copy of this completed form. The signing official
named on this application to represent the current permittee must meet one of the following:
a. Corporation — a principle executive officer of at least the level of vice-president;
b. Limited Liability Company (LLC) — a manager or company official as those terms are defined
in G.S. 57D "North Carolina Limited Liability Company Act;"
c. Public Entity — a principal executive officer, ranking official, or other duly authorized employee;
d. Partnership or limited partnership — the general partner;
e. Sole proprietor; or
f. Letter of authorization signed by one of the signatories noted in a — e above authorizing the
signature of another entity.
3. One hard copy and one electronic copy of recorded documents required by the original permit that
have not yet been received by DEMLR, including: deed restrictions, protective covenants,
condominium/planned community declaration and easements. If the project has been built, include
documentation that the maximum BUA per lot or maximum total BUA has not been exceeded. If
the project has not been built, include a signed agreement that the final recorded deed restrictions
and protective covenants will be submitted at a later date.
4. O&M Agreements, Please select one:
❑ I have a copy of the current recorded O&M Agreement for all SCMs, and I will continue to
keep this on file with the permit; or
❑ I do not have a copy of the current recorded O&M Agreement for all SCMs and am
requesting a copy be sent to me. I agree to keep this on rile with the permit.
5. Designer Certifications, Please select one:
❑ A copy of the certification(s) confirming that the project was built in accordance with the
approved plans have been previously provided to the Division; or
❑ A copy of the certification(s) confirming that the project was built in accordance with the
approved plans are enclosed; or
❑ The project has not yet been built.
6. [IF APPLICABLE] If the project has been built, one original hard copy and one electronic copy of a
signed, sealed, and dated letter from a licensed professional stating that the SCMs have been
inspected, and that they have been built and maintained in accordance with the permit.
DL 7. [IF APPLICABLE] When the permittee is a corporation or a limited liability corporation (LLC): Provide
one hard copy 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).
https://www.sosnc.gov/online services/search/by title/ Business Registration
Stormwater Permit Renewal Application Form Page 2 of 3 May 11, 2018

D. PERMITTEE'S CERTIFICATION
I, Dr /} N G CL 17KE , the person legally responsible for the permit, certify that I have
a copy of the Permit and O&M Agreement on site (or I will obtain a copy and it will be kept on site), that I am
responsible for the performance of the maintenance procedures, and the site has been and will be maintained
according to the O&M Agreement and approved plans. I agree to notify DEMLR of any problems with the SCMs
or built -upon area and to submit the proper forms to modify or transfer the permit prior to any changes to the
project, SCMs, or ownership. All information provided on this permit renewal application is, to the best of my
knowledge, c rect and complete ,
Signature: Date: -E; ! Z53 1 z I
NOTARIZATION:
that
aay or
State of Montana
Residing at Poison Montana
rd#y Commission Expires
January 01, 2023
a Notary Public for the State of
County of I AUK , do hereby certify
personally appeared before me
20 and acknowledge the due
Witness my hand and official seal,
Notary Signature: 9& l 11 VN
My commission expires 01-01- aw
Stormwater Permit Renewal Application Form Page 3 of 3 May 11, 2018

7f;' l LIMITED LIABILITY COMPANY ANNUAL REPORT
0
lame
NAME OF LIMITED LIABILITY COMPANY: 1424 VALENCIA STREET, LLC
SECRETARY OF STATE ID NUMBER: 1628936 STATE OF FORMATION: MT
REPORT FOR THE CALENDAR YEAR: 2021
SECTION A:
1. NAME OF REGISTERED AGENT: CT Corporation SYStem
2. SIGNATURE OF THE NEW REGISTERED AGENT:
- Filed Annual
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS B COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
160 Mine Lake Ct Ste 200
160 Mine Lake Ct Ste 200
Raleigh, NC 27615 Wake County Raleigh, NC 27615
SECTION B: PRINCIPAL OFFICE INFORMATION
1. DESCRIPTION OF NATURE OF BUSINESS: Manage real estate
2. PRINCIPAL OFFICE PHONE NUMBER: (406) 5523-2500
4. PRINCIPAL OFFICE STREET ADDRESS
3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
5. PRINCIPAL OFFICE MAILING ADDRESS
7403 Highline Ct 7403 Highline Ct
Missoula, MT 59808 Missoula, MT 59808
6. Select one of the following If applicable. (Optional see Instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Diane Litke. NAME:
TITLE: Member
ADDRESS:
7403 Highline Ct
Missoula, MT 59808
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
Diane Litke
SIGNATURE
Foml must be signed by a Company Official fisted under Section C of This form.
4/2/2021
DATE
Diane Litke Member
Print or Type Name of Company Official Prim or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State, Business Registration Division, Post Office Box 29525. Raleigh. NC 2762M525

CVS Pharmacy Store #7344 - Havelock
Stormwater Permit No. SW7131013
Craven County
Designer's Certification
c�a�r
OCT 2 9 2014
I, W. ao rdatn R r e.w , as a duly registered Profe S s =no I rn Ineerin the
State of North Carolina, having been authorized to observe Cperi�odicall weekly/ full
time) the construction of the project,
LUS Pk,,r,-xo,cy S'Fore, # 7344 — Hmve,lock � MC,
(Project)
for L VS 7 3 I `l- Alt, L L G (Project Owner) hereby state that, to the
best of my abilities, due care and diligence was used in the observation of the project
construction such that the construction was observed to be built within substantial
compliance and intent of the approved plans and specifications.
The checklist of items on page 2 of this form is included in the Certification.
Noted deviations from approved plans and specification:
p.
Signature
Registration Number
Date 10 AL? l;LO I N
SEAL
=�P�`e s o�d:y��4
QQo t
SEAL
039196 i
!�GINE
OgpA1N 1g`
Page 6-of 7

I
I
Certification Requirements:
✓ 1. The drainage area to the system contains approximately the permitted
acreage.
J 2. The drainage area to the system contains no more than the permitted
amount of built -upon area.
✓ 3.
-L4.
—J-5.
✓ 6.
__/ 7.
J11
�12
13
114
J 15.
All the built -upon area associated with the project is graded such that the
runoff drains to the system.
All roof drains are located such that the runoff is directed into the system.
The outlet/bypass structure elevations are per the approved plan.
The outlet structure is located per the approved plans.
Trash rack is provided on the outlet/bypass structure.
All slopes are grassed with permanent vegetation.
Vegetated slopes are no steeper than 3:1.
The inlets are located per the approved plans and do not cause short-
circuiting of the system.
The permitted amounts of surface area and/or volume have been
provided.
Required drawdown devices are correctly sized per the approved plans.
All required design depths are provided.
All required parts of the system are provided, such as a vegetated shelf,
and a forebay.
The required system dimensions are provided per the approved plans.
r
Page 7 of 7
r�
,fe - -

333 Fayetteville Street,
Kimley-Horn Suite 600
�_❑ and Associates, Inc. Raleigh, North Carolina
27601
TEL [phone]
FAX [phone]
Transmittal
Date: 10/27/ 14 Job Number: 012426066
I
Project Name: CVS Pharmacy - Havelock, NC
To: NCDENR - Stormwater Permitting Unit 1"^` A V,',�
ATTN: Mr. Samir Dumor, P.E.
943 Washington Square Mall OCT 9 Q 2014
Washington, North Carolina 27889
[phone]
We are sending these by "" "'" . .. 11 — - _
❑ U.S. Mail ® FedEx ❑ Hand Delivery
❑ Other
We are sending you
10 Attached ❑ Under separate cover via rhefolloming items:
❑ Shop drawings ❑ Prints/Plans ❑ Samples ❑ Specifications ❑ Change Orders
® Other NCDENR Storrmvater Certification
Copies Date No. Description
I copy 10/27/14 CVS Havelock Stormwater Management Certification
These are transmitted as checked below:
M For your use ❑ Approved as submitted
❑ Resubmit
❑ Copies for approval
❑ As requested ❑ Approved as noted
® Submit
® Copies for distribution
❑ For review and comment ❑ Returned for corrections
❑ Return
❑ Corrected prints
Remarks: If you have any questions or comments, please feel free to contact me directly at
[phone].
Copy to: File
Signed:
Jordan Brewer, P.E.

D
Permit Number:
OCT 18 2013 (to be provided by DHQ)
J)EM Drainage Area Number:
Stormwater Wetland' Operat on and Maintenance Agreement
I will keep a maintenance record on this BMP. This maintenance record will be kept in a log in a
known set location. Any deficient BMP elements noted in the inspection will be corrected, repaired or
replaced immediately. These deficiencies can affect the integrity of structures, safety of the public, and
the removal efficiency of the BMP.
Important maintenance procedures:
— Immediately following construction of the stormwater wetland, bi-weekly inspections will be
conducted and wetland plants will be watered bi-weekly until vegetation becomes established
(commonly six weeks).
— No portion of the stormwater wetland will be fertilized after the first initial fertilization that is
required to establish the wetland plants.
— Stable groundcover will be maintained in the drainage area to reduce the sediment load to the
wetland.
— Once a year, a dam safety expert should inspect the embankment.
After the stormwater wetland is established, I will inspect it monthly and within 24 hours after every
storm event greater than 1.0 inches (or 1.5 inches if in a Coastal County). Records of operation and
maintenance will be kept in a known set location and will be available upon request.
Inspection activities shall be performed as follows. Any problems that are found shall be repaired
immediately.
1113MP element:
Potential roblenn: ,
How I will reniediate the ioblerii:
Entire BMP
Trash/debris is present.
Remove the trash/debris.
Perimeter of wetland
Areas of bare soil and/or erosive
Regrade the soil if necessary to remove the
gullies have formed.
gully, and then plant a ground cover and
water until it is established. Provide lime
and a one-time fertilizer application.
Vegetation is too short or too long.
Maintain vegetation at an appropriate
height.
Inlet device: pipe or
The pipe is clogged (if applicable).
Unclog the pipe. Dispose of the sediment
Swale
offsite.
The pipe is cracked or otherwise
Replace the pipe.
if applicable).
-damaged
Erosion is occurring in the Swale (if
Regrade the Swale if necessary to smooth
applicable).
it over and provide erosion control
devices such as reinforced turf matting or
riprap to avoid future problems with
erosion.
Form SW401-Wetland O&M-Rev.4
Page 1 of 3

Permit Number:
(to be provided by UIVQ)
Forebay
Deep pool, shallow water
and shallow land areas
Micropool
Outlet device
Receiving water
Sediment has accumulated in the
forebay to a depth that inhibits the
forebay from functioning well.
Erosion has occurred.
are present.
Algal growth covers over 50% of the
deep pool and shallow water areas.
Cattails, phragmites or other invasive
plants cover 50% of the deep pool and
shallow water areas.
Shallow land remains flooded more
than 5 days after a storm event.
Plants are dead, diseased or dying.
Best professional practices show that
pruning is needed to maintain optimal
plant health.
Sediment has accumulated and
reduced the depth to 75% of the
original design depth of the deep
pools.
A tree has started to grow on the
embankment.
An annual inspection by appropriate
professional shows that the
Evidence of muskrat or beaver activity
is present.
Sediment has accumulated and
reduced the depth to 75% of the
original design depth.
Clogging has occurred.
The outlet device is damaged
Erosion or other signs of damage have
occurred at the outlet.
How I will remediate the problem:
Search for the source of the sediment and
remedy the problem if possible. Remove
the sediment and dispose of it in a location
where it will not cause impacts to streams
or the BMP.
Provide additional erosion protection such
as reinforced turf matting or riprap if
needed to prevent future erosion
Remove the weeds, preferably by hand. If
a pesticide is used, wipe it on the plants
rather than spraying.
Consult a professional to remove and
control the algal growth.
Remove invasives by physical removal or
by wiping them with pesticide (do not
spray) - consult a professional.
Unclog the outlet device immediately.
Determine the source of the problem:
soils, hydrology, disease, etc. Remedy the
problem and replace plants. Provide a
one-time fertilizer application to establish
the ground cover if necessary.
Prune according to best professional
practices.
Search for the source of the sediment and
remedy the problem if possible. Remove
the sediment and dispose of it in a location
where it will not cause impacts to streams
or the BMP.
Consult a dam safety specialist to remove
the tree.
Make all needed repairs.
Consult a professional to remove muskrats
or beavers.
Search for the source of the sediment and
remedy the problem if possible. Remove
the sediment and dispose of it in a location
where it will not cause impacts to streams
or the BMP.
Clean out the outlet device. Dispose of the
sediment off -site.
Repair or replace the outlet device.
Contact the NC Division of Water C
401 Oversight Unit at 919-733-1786.
Form SW401-Wetland O&M-Rev.4 Page 2 of 3

Permit Number:
(to be provided by DIPO)
I acknowledge and agree by my signature below that I am responsible for the performance of the
maintenance procedures listed above. I agree to notify DWQ of any problems with the system or prior
to any changes to the system or responsible party.
Project name:CVS Pharmacy Store # 7344
BMP drainage area number:
Print name:Tim Register- Hart -Redd, LLC
Address:455 North Ingold Avenue, Garland. NC 28441
Note: The legally responsible party should not be a homeowners association unless more than 50% of the lots have been
sold and a resident of the subdivision has been named the president.
I, �%-lw ;> , a Notary Public for the State of
,yo..:il OO"O/'W.. , County of Snej..✓ , do hereby certify that
/7-- Zs:sioz personally appeared before me this 7 day of
eezo,se'r— 0,�a13 , and acknowledge the due execution of the forgoing stormwater wetland
maintenance requirements. Witness my hand and official seal,
SEAL
My commission expir�-2 a--2-14 31. Zo t Fs--
Form SW401-Wetland O&M-Rev.4 Page 3 of 3

ATA OCT 18 2013 �0F `NA7FgO
NCDENR 1n II �y,
STORMWATER MANAGEMENT PERMIT APPLICATFORM
401 CERTIFICATION APPLICATION FORM
WETLAND SUPPLEMENT
This form must be filled out, printed and submitted.
The Required Items Checklist (Part 111) must be printed, filled out and submitted along with all the required information.
I. PROJECT INFORMATION
Project name CVS Pharmacy #7344
Contact name Chris Bostic
Phone number 919-653-2927
Date October 3, 2013
Drainage area number 1
1l. DESIGN INFORMATION
Site Characteristics
✓�
1 a eU
Drainage area
28,750.00 f? 5�
p�-r�'�`��
Impervious area
18,250.00 f?
Percent impervious
63.5% %
Design rainfall depth
1.50 inch
Peak Flow Calculations
"H
1-yr, 24-hr rainfall depth
3.58 in
��
1-yr, 24-hr intensity
0.15 Whir
Z'� •"' ,
O,y.•5
Pre -development 1-yr,•24-hr runoff
ft3/sec
2
2 9r'ty
Post -development 1-yr, 24-hr runoff
ft3/sec
i
SEAL
Pre/Post 1-yr, 24-hr peak control
ft'/sec
037453 I
Storage Volume: Non -SA Waters
Minimum required volume
2,233.00 it
s,O�;..,G1NE_:•'
Volume provided (temporary pool volume) 3,305.00 It t/
Storage Volume: SA Waters Parameters
1.5" runoff volume it
Pre -development 1-yr, 24-hr runoff volume it
Post -development 1-yr, 24-hr runoff volume 0.00 it
Minimum volume required 0.00 it
Volume provided 5,847.00 f13
Outlet Design
Depth of temporary pool/ponding depth (DP n1J 12.00 in
Drawdown time 2.21 days
Diameter of orifice 1.00 in
Coefficient of discharge (Cu) used in orifice diameter
0.60 (unitless)
calculation
Driving head (Ha) used in the orifice diameter calculation 0.50 it
OK ...... ,,,.
161.4
OK
OK
Drawdown orifice diameter maybe insufficient. Please provide
adequate supporting calculations.
OK
Form SW401-;Wetland-Rev.6 :11/16/09--
.-.
Parts I and II. Project Design Summary, Page 1 of 3

Surface Areas of Wetland Zones
Surface Area of Entire Wetland
3,305.00 le
OK
Shallow Land
1,215.00 ft2
OK
The shallow land percentage is:
37% %
Shallow Water
1,263.00 ft2
OK
The shallow water percentage is:
38% %
Deep Pool
Forebay portion of deep pool (pretreatment)
386.00 ft2
OK
The forebay surface area percentage is:
12% %
Non-forebay portion of deep pool
436.00 ft 2
OK
The non-forebay deep pool surface area percentage is:
13% %
Total of wetland zone areas
3,300.00 fiz
Enter data into the shaded cells in this section.
Add or subtract the following area from the zones
-5.00 ft2
Topographic Zone Elevations
Temporary Pool Elevation (TPE)
Shallow Land (top)
25.00 It amsl
Permanent Pool Elevation (PPE)
Shallow Water/Deep Pool (top)
24.00 It amsl
Shallow Water bottom
23.50 ft amsl
Most shallow point of deep pool's bottom
24.00 fl amsl
Deepest point of deep pool's bottom
21.00 It amsl
Design must meet one of the following two options:
This design meets Option #1,
Y (Y or N)
Top of PPE is within 6" of SHWT, If yes:
SHWT (Seasonally High Water Table)
24.00 it amsl t/ OK
This design meets Option #2,
(Y or N)
Welland has liner with permeability < 0.01 in/hr, If yes:
Depth of topsoil above impermeable liner
in
Topographic Zone Depths
Temporary Pool
Shallow Land
12.00 in OK
Permanent Pool
Shallow Water
6.00 in OK
Deep Pool (shallowest)
0.00 in
Deep Pool (deepest)
36.00 in OK
Planting Plan
Are cattails Included in the planting plan?
N (Y or N)
OK
Number of Plants recommended in Shallow Water Area:
Herbaceous (4'cubic-inch container)
350
Number of Plants recommended in Shallow Land Area:
Herbaceous (4'cubic-inch container), OR
350
Shrubs (1 gallon or larger), OR
56
Trees (3 gallon or larger) and Herbaceous (4+cubic-inch)
7 and
280
Number of Plants provided in Shallow Water Area:
Herbaceous (4' cubic -inch container)
408
OK
Number of Plants provided in Shallow Land Area:
Herbaceous (4' cubic -inch container)
190
More required if not planting shrubs or trees.
Shrubs (1 gallon or larger)
56
OK
Trees (3 gallon or larger) and
0
More required if not planting herb, and/or shrubs.
Grass -like Herbaceous (4+cubic-inch)
Form SW401-Wetland-Rev.6-11/16/09 " - - Pans I and If. Project Design Summary, Page 2 of 3

Additional Information
Can the design volume be contained?
Y
(Y or N)
OK
Does project drain to SA waters? If yes,
N
(Y or N)
Excess volume must pass through filter.
What is the length of the vegetated filter?
ft
Are calculations for supporting the design volume provided in the
Y
Y or N
( )
OK
application?
Is BMP sized to handle all runoff from ultimate build -out?
Y
(Y or N)
OK
Is the BMP located in a recorded drainage easement with a
Y
(Y or N)
OK
recorded access easement to a public Right of Way (ROW)?
The length to width ratio is:
2.71 :1
OK
Approximate wetland length
95.00 It
Approximate wetland width
35.00 it
Approximate surface area using length and width provided
3,325.00
It e
This approx, surface area is within this number of square feel
of the entire wetland surface area reported above:
Will the wetland be stabilized within 14 days of construction?
Y
(Y or N)
OK
Form SW401 Wetland-Rev.6-11/16/09 ' Pans I and H. Project Design Summary, Page 3 of 3

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT L 2 G
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
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 N/A in the blank.)
Part A.
1. Project Name CVS Pharmacy Store #7344
2. Location of land -disturbing activity: County Craven City or Township Havelock
Highway/Street US 70 Service Road(SR 1823) and Catawaba Road Latitude 340 54' 39.38" N
Longitude 760 56' 11.01" W
3. Approximate date land -disturbing activity will commence: November 2013
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.21 acres
6. Amount of fee enclosed: $ 195 . The application fee of $65.00 per acre (rounded up to
the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Tim Register E-mail Address timregister(a)intrstar.net
Telephone [phone] Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Baldrees Properties, LLC
Name Telephone r E d E
516 Lilliput Drive 103 Catawaba Road U OCT 18 2013 D
Current Mailing Address Current Street Address
IANp O JAUrf SECInON
New Bern NC 28562 Havelock INC wnsruNcr<NAL0FJ90E
City State Zip City State Zip
Deed Book No. 2945 Page No. 0866 Provide a copy of the most current deed.
Landowner(s) of Record (attach accompanied page to list additional owners):
Jaybird Properties, LLC
Name
110 Riverdale Road
Current Mailing Address
New Bern NC 28562
City State Zip
Telephone
Current Street Address
Fax Number
Havelock NC 28532
City State Zip
Deed Book No. 1767 Page No. 0561 Provide a copy of the most current deed.
r�.

Part B.
N.
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):
Hart -Redd. LLC timreoisterintrstar.net
Name E-mail Address
2948 Sidco Drive 2948 Sidco Drive
Current Mailing Address Current Street Address
Nashville TN 37204 Nashville TN 37204
City State Zip City State Zip
Telephone [phone] Fax Number [phone]
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:
Tim Register timregister(a7intrstar.net
Name E-mail Address
455 North Ingold Avenue
Current Mailing Address
Garland NC 28441
City State Zip
455 North Inoold Avenue
Current Street Address
Garland NC 28441
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:
Name of Registered Agent
Current Mailing Address
City State Zip
E-mail Address
Current Street Address
City
Fax Number
State Zip

1 NW
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.
Tim Register Agent
Type oft name Title or Authorit
Signature Date
I, '-� , a Notary Public of the County of S.o.ps.✓
State of North Carolina, hereby certify that /: /`f�5 3� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this % day of ocToAre- 20 i3
My commission expires.�e"A,,vy/ 3/ ..90/8-