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HomeMy WebLinkAboutNCC222091_NOI Signed Certification_20220613NCG01 Notice of Intent (NOI) Certification Form Directions: Print this form, complete, scan and upload to the electronic N01. Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at: Division of Energy, Mineral & Land Resources Stormwater Program 512 N. Salisbury Street, 61, Floor (Office 640K) 1612 Mail Service Center Raleigh, NC 27699-1612 DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE. THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221 Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). Under penalty of law, I certify that (check all boxes to indicate your agreement): 0 I am the person responsible for the construction activities of this project, for satisfying the requirements of this permit, and for any civil or criminal penalties incurred due to violations of this permit. Q✓ The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information. ❑✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control Plan. ❑✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution Prevention Plan) of the NCGO10000 General Permit. I will nonetheless ensure that all conditions of Part II of the permit are met on the project at all times. �✓ 1 hereby request coverage under the NCG010000 General Permit and understand that coverage under this permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an individual permit. Project Name (must match Ala): Dollar General - Mamers Road Specific Lot Numbers (must match Alb): Permittee (must match B1): Rl1etson Companies, Inc. Legally Responsible Person (must match 132 & B3): Jamie EnCinosa Title of Legally Responsible Person (must match 133b): EVP Of Operations Name & Title of Signed if Authorized Individual Differs from Legally Responsible Person: Phone Number: 910-944-0881 6/1 /20 ature of Legally Responsible Person or Authorized Individual Date IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity, such as a president secretary, treasurer, or vice president or a manager that is authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit. d# O (� ry Wqq r �o NORTH C.A;iOLINA Enrtrnnmentu� Qvoiiry A. Project Information NOTE: If you save a draft of this application, do not save it with uploaded attachments. This may cause problems when you resume editing the draft and try to submit it. Remove all uploaded attachments before saving a draft. Upload necessary documents only when you are ready to submit the eNOI. Part A. Proiect Location and Waterbodv Information Are you submitting • No an NOI that was Yes rejected before? 1a. Project Name* Dollar General - Manners Road 1 b. Specific Lot This field may be used to list specifc lot numbers. Numbers 1 c. Parcel ID List all PINs associated with this project Number(s) (PIN)* 0610-87-8640 , 0610-87-9549 , and 0610-97-0587 2. County* Harnett 3. Highway or Street US 421 N and Manners Rd Address* Street name only is acceptable if no address number assigned yet 4. City or Township* Lillington 5. State* NC lJ 6. Zip Code* 27546 7. Latitude* Enter the latitude in decimal degrees 35.4195 8. Longitude* Enter the longitude in decimal degrees (MUST be negative) -78.9359 If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of North Carolina. Look for the coordinates in the bottom left corner. 9. Date to Begin* 06/10/2022 Estimated Construction Project Start Date 10. Date to End* 12/15/2022 Estimated Construction Project End Date 11. SIC (Primary)* Commercial (1542) Standard Industrial Classification for Development 12. Acres to be IMPORTANT: Must match E&SC Plan Approval Letter or Grading Permit disturbed* 2.00 (including off -site borrow and waste areas) 13. Total site area 1.54 (acres) * 14. Post -construction 0.92 impervious area (Estimated) (acres) * Below you must enter waterbody information for surface waters affected by this project. Please consult DWR's Surface Water Classifications Map Viewer to find waterbody name and corresponding index number. Please enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You may enter up to 3 waterbodies if needed. 15a. Receiving Camels Creek Waterbody* Name of waterbody into which stormwater runoff will discharge 15b. Waterbody Index 18-12-(2) No. * NC Waterbody Index Number Stormwater ✓ No discharges will flow Yes to additional waters* 16a. Is this project O Yes subject to the NC Q No, not subject to NC SPCA Sediment Pollution Control Act?* Note: Stormwater discharges from construction activities associated with oil and gas exploration, production, processing, treatment, or transmission facilities are eligible for the exemption from NPDES permit coverage except in very limited instances. Do not proceed with this application before consulting this EPA fact sheet and verifying a permit applies. B. Permittee Information Part B. Permittee Information - Legally Responsible Entity and Individual ................................................................................................................................................................................................................................................................................................................................................................................................. Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application form must be the same person as listed in THIS SECTION, or an authorized responsible individual within the same organization. That person must be a responsible corporate officer who owns or operates the construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of that permit. 1. Permittee* Legally Responsible Entity Rhetson Companies, Inc. If permittee is an individual, enter first and last name in this field. Otherwise, enter organization/business name. Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the registration here. Permittee must be the same entity that is responsible for the land -disturbing activity as listed on the NC SPCA Financial Responsibility/Ownership (FRO) Form. 2. First Name* Jamie 3. Last Name* Encinosa 3b. Title* EVP of Operations 4. Permitee E-mail jamie@rhetson.com Address* 5. Permittee 910-944-0881 Telephone No.* 6. Permittee Mailing Street Address Address* 2075 Juniper Lake Road Address Line 2 City State / Province / Region West End NC Postal / Zip Code Country 27376-8919 us Check box if the O✓ Yes street address the same as mailing address 7. Permittee Street Street Address Address* 2075 Juniper Lake Road Address Line 2 City State / Province / Region West End NC Postal / Zip Code Country 27376-8919 us 8. Type of Ownership is only individual if an individual is named in B.1. above. Ownership* Non -Government C. Site Contact information Part C. Project Site Contact Information ..................................................................................................................................................................................................................................................................................................................................................................................................... 1. Primary Site John Contact - First Name* 2. Primary Site Parker Contact - Last Name* 3. Title Project Manager 4. Site Contact E-mail John@rhetson.com Address* This person will be copied on all correspondence. 5. Site Contact 910-944-0881 Telephone No.* 6. Organization Name Rhetson Companies 7. Site Contact Street Address Mailing Address* 2075 Juniper Lake Road Address Line 2 City West End Postal / Zip Code 27376-8919 8. Consultant Name (Optional) First and Last name 9. Consultant E-mail This person will be copied on all correspondence. 10. Consultant Telephone No. Verify billing contact information and revise if necessary. 11. Billing E-mail* (For Annual Fee correspondence) john@rhetson.com Default is legally responsible person e-mail 12. Billing (For Annual Fee correspondence) Telephone* 910-944-0881 Default is legally responsible person telephone State / Province / Region NC Country us D. E&SC Plan Part D. Erosion & Sediment Control (E&SC) Plan Approval Information ..................................................................................................................................................................................................................................................................................................................................................................................................... 1. Date E&SC Plan 04/22/2022 Approved * 2. E&SC Plan Project HARNE-2022-099 Number/ID* Assigned by agency or local program 3. E&SC Plan L State DEQ Office Approved by* 0 Local Program 4. State DEQ Office* Fayetteville Regional Office (FRO) Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can include the beginning point and end point coordinates in the "Notes" box below). 5. E&SC Plan Approval documentation only! DO NOT upload entire set(s) of E&SC Plans Approval letter or NCDEQ Erosion Permit.pdf 786.58KB Grading Permit* Must be PDF format 6. Signed FRO* Financial Responsibility/Ownership Form Financial Responsibility Form-Signed.pdf 147.38KB Must be PDF format 7. Site Location Map* Must be PDF format (limit 20 MB) Site Location Map.pdf 9.55MB Please do not upload entire set of E&SC plans. 8. Notes (Optional) Provide any additional information that might help the reviewer better understand how uploaded documents support the application. Include additional waterbodies if necessary. 9. NOI Certification NOI Certification Form.pdf 783.31 KB Form* Manners eNOI Signed.pdf 315.07KB Must be PDF format YOU MUST MAIL THE ORIGINAL SIGNED NOI CERTIFICATION FORM (click on this link) to The Stormwater Program at the address on the form for the application to fulfill federal application requirements. The Certification Form must be signed by the person listed in Section B (Permittee Information) or by an authorized responsible person within the same organization. NOTE: The person who signs the paper form must be the same person to electronically certify and sign the eNOI. This is an Express O No Review Project* 0 Yes E. Certification North Carolina General Statute 143-215.613 (1) provides that: Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). Under penalty of law, I certify that: * O✓ I am the person responsible for the construction activities of this project, for satisfying the requirements of this permit, and for any civil or criminal penalties incurred due to violations of this permit. * O✓ The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information. * O✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control Plan. * O✓ I hereby request coverage under the NCG010000 General Permit and understand that coverage under this permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an individual permit. Specify if you are:* O The Legally Responsible Person named on this Notice of Intent V Authorized Responsible Person* (signing on behalf of Legally Responsible Person named in Part B) Important: The person who electronically signs this Certification above must be the same person who signs the NOI Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible person within the same organization as the Permittee. *An authorized individual is a responsible corporate officer who owns or operates the construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of that permit. Signature* Type Name* Jamie Encinosa Title* EVP of Operations Organization* Legally Responsible Entity Rhetson Companies, Inc. Date* 06/01 /2022