SWA000210_Supplemental Info Review_20230613

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 6/13/2023 1:53:40 PM (Supplemental Submittal)
Accept by Kaitlin Peck 6/14/2023 10:18:50 AM (Supplemental Info Submittal)
• The task was assigned to bethany.georgoulias 6/13/2023 1:53:41 PM
• bethany.georgoulias reassigned the task to Kaitlin Peck 6/14/2023 7:43:08 AM

=DEQ •
Submittal from 6/13/2023
Permit Information:
Please provide specific permit details below.
................................................................................................................................................................................................................................................................................................................................................................................................
What Type of Permit? Choose one:
* NPDES Industrial or MS4 Permit
State Stormwater(Post-Construction)Permit
Other
Permit Number* SWA000210
Begins with"SW","NCG",or"NCS"
What DEQ Office is Reviewer:Please correct if misidentified,close this review form,and reassign task to the appropriate contact.
the Primary Contact? Central Office
*
Washington Regional Office(Attn: Carl Dunn)
Wilmington Regional Office(Attn:Christine Hall)
................................................................................................................................................................................................................................................................................................................................................................................................
Project Name* Love's Travel Stop
Owner/Operator* Roserock Holdings, LLC
County: Forsyth
Submitter Name:* Jeremy Reese
Who is submitting this information?
E-mail Address:* [e-mail]
Phone Number* 8506332302
Additional E-mail for (Optional)
Submittal
Confirmation:
State Stormwater (Post-Construction) Information Uploads
Choose file type and upload attachment(Reviewer may remove unnecessary submittals)
File Type* Application Form
File Upload Click the upload button,or drag and drop files to attach
01_ATC Permit Application Form.pdf 3.61 MB
Only PDF files are accepted.
File Type* USGS Topographic Site Map
File Upload Click the upload button,or drag and drop files to attach
03_USGS Map.pdf 280.9KB
Only PDF files are accepted.
File Type* Plansheet-Proposed Conditions/Site Plan

File Upload Click the upload button,or drag and drop files to attach
04_Site Plan.pdf 929.49KB
Only PDF files are accepted.
File Type* Construction Sequence
File Upload Click the upload button,or drag and drop files to attach
05_Construction Sequence.pdf 229.75KB
Only PDF files are accepted.
File Type* Property Deed
File Upload Click the upload button,or drag and drop files to attach
06_Property Deed.pdf 112.65KB
Only PDF files are accepted.
File Type* Signing Official Title&Position Information
File Upload Click the upload button,or drag and drop files to attach
07_NC Sec of State Annual Report-Love's.pdf 741.18KB
Only PDF files are accepted.
File Type* Lease Agreement
File Upload Click the upload button,or drag and drop files to attach
09_Master Lease Agreement.pdf 396.66KB
Only PDF files are accepted.
Is this project funded No
with ARPA grant Yes
funds?
Uploads contain NO
Confidential YES
Information* NOTE:The following information cannot be claimed as confidential:the name and address of any permit applicant
or permittee,permit applications,permits,effluent data,information required by NPDES application forms provided
by the Director inclusive of all forms and attachments[Ref.40 CFR 122.7(b)and(c)].
Notes about the attachments:
* By checking the box and signing box below, I certify that:
o I have given true,accurate,and complete information on this form;
o I agree that submission of this Supplemental Information form is a"transaction"subject to Chapter 66,Article 40 of the
NC General Statutes(the"Uniform Electronic Transactions Act")
o I agree to conduct this transaction by electronic means pursuant to Chapter 66,Article 40 of the NC General Statutes
(the"Uniform Electronic Transactions Act");
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature;AND
o I intend to electronically sign and submit the Supplemental Information Upload form.
Full Name:* Jeremy Reese
Signature: ��7

Date Submitted: 06/13/2023

Initial Review
Verify Permit No.* IMPORTANT:REVIEWER SHOULD VERIFY and revise here if necessary.
SWA000210
Who needs a Copy?* Reviewer selections will only be required for offices checked here.
Central Office Staff
Regional Office Stormwater Contact
State Stormwater RO Staff
No Copy Needed
Central Office Reviewer:*
Notifies CO Staff with Email
Jim Farkas
Any Comments or
Added Info for CO
Staff Reviewer?
Review Date* 06/14/2023