NCC192265_NOI Application_20191009

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/8/2019 8:22:33 AM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 10/9/2019 1:11:04 PM (Review- Construction NOI 16865)
• Georgoulias, Bethany reassigned the task to Georgoulias, Bethany 10/9/2019 12:34 PM
• The task was assigned to Farkas, Jim J by round robin distribution 10/8/2019 8:22 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 10, 2019 5:00
PM 10/8/2019 8:22 AM
Submit by McCoy, Suzanne 10/9/2019 2:43:26 PM (Payment Verification for NCC192265)
* Mavis Tire Supply LLC
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/9/2019 2:42 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 20, 2019 5:00
PM 10/9/2019 1:11 PM

117-8) &T:M'G) M F1Ii f_TiI a 10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Hickory Mavis Discount Tire
2. County* Catawba
3. Highway or Street 2930 N Center St.
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* Hickory
5. State * NC
6. Zip Code* 28601
7. Latitude * Enter the latitude in decimal degrees
35.7710
8. Longitude * Enter the longitude in decimal degrees (WISTbe negative)
-81.3300
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* 10/03/2019
Estimated Construction Project Start Date
10. Date to End* 02/04/2020
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 1.17
disturbed* (including off -site borrow and waste areas)
13. Total site area
1.17
(acres)*
14. Post-
0.75
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-CATAW-2019-Hickory Mavis Discount Tire
Tracking ID
Assigned automatically

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 Catawba River
Waterbody* Narre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-(53)
Index No. * NCWaterbody Index Nunber
Stormwater rJ No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project r Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
Important: The person who signs the NOI Certification Form and signs the Certification in Section E of this application
form should 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. Organization Mavis Discount Tire Supply, LLC
Name *
2. First Name* Jeff
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Gordon
If Corporation, enter Registered Agent Last Barre
3b. Title Senior Vice President of Real Estate
4. Permitee E-mail [e-mail]
Address*
5. Permittee 914-919-9819
Telephone No.*
6. Permittee Mailing Street Address
Address* 358 Saw Mill River Road
Address Line 2
City
Millwood
Postal / Zip Code
10546
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
358 Saw Mill River Road
Address Line 2
City
Millwood
Fbstal / Zip Code
10546
State / Province / Region
W
Country
us
State / Province / Region
W
Country
us

C. Site Contact Information
Part C.
Proiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Trey
Contact - First
Name *
3. Primary Site Bates
Contact - Last
Name *
4. Title
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 978-218-9511
Telephone No.*
7. Organization
Davies General Contracting, LLC
Name
8. Site Contact
Street Address
Mailing Address*
2421 East Lake Road
Address Line 2
city
McDonough
Fbstal / Zip Code
30252-4963
9. Consultant Name (optional)
Wyatt Bone
First and Last nacre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11.Consultant 919-578-9000
Telephone No.
State / Province / Region
GA
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 05/20/2019
Approved *
2. E&SC Plan Project CBPR-06-2017-26730
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Catawba County
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application.
5. E&SC Plan Mavis Tires approval (with acreage) May 20 62.87KB
Approval 2019.pdf
letter/documentation
Mist be RJF format
6. NOI Certification NOI - signed 2019.10.08.pdf 432.91KB
Form Mast be RDF format
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
rJ 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.
* V 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* V If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit, I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* I7 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:* r The Responsible Person named on this Notice of Intent
r Authorized Responsible Person'
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* Jeff Gordon
Title Senior Vice President of Real Estate
Organization Mavis Discount Tire Supply, LLC
Date * 10/08/2019

F. Tracking and COC Info
NOI Tracking No. 16865
NC Reference No. NCG01-2019-2265
Uses 'count number variable (incremrented by SP)
Certificate of NCC192265
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2265
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)