NCC192339_NOI Application_20191023

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/14/2019 11:46:36 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 10/14/2019 12:31:30 PM (Review- Construction NOI 17135)
• The task was assigned to Garcia, Lauren V by round robin distribution 10/14/2019 11:47 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 16, 2019 5:00
PM 10/14/2019 11:47 AM
Submit by McCoy, Suzanne 10/23/2019 1:42:40 PM (Payment Verification for NCC192339)
* Stimmel Associates PA
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/23/2019 1:40 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 25, 2019 5:00
PM 10/14/2019 12:31 PM

1 r-i) iTiT 7i) M 1i1 f_TiI a 10141
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * McDonald's - Smith Crossing
2. County* Forsyth
3. Highway or Street 1480 Jag Branch Blvd
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Kernersville
5. State * NC
6. Zip Code* 27284
7. Latitude * Enter the latitude in decirral degrees
36.0793
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.1067
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* 11/18/2019
Estimated Construction Project Start Date
10. Date to End* 02/27/2020
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 1.40
disturbed* (including off -site borrow and waste areas)
13. Total site area
1.50
(acres)*
14. Post-
0.93
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-FORSY-2019-McDonald's - Smith Crossing
Tracking ID
Assigned autorratically

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 Abbotts Creek
Waterbody* Nbrre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 12-119-(1)
Index No. * NCWaterbody Index Pbnber
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 McDonald's USA, LLC
Name *
2. First Name* Leo
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Van Buuren
ff Corporation, enter Registered Agent Last Barre
3b. Title Area Construction Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 1-919-931-2845
Telephone No.*
6. Permittee Mailing Street Address
Address * 110 N Carpenter St
Address Line 2
City
Chicago
Postal / Zip Code
60607
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
110 N Carpenter St
Address Line 2
City
Chicago
Fbstal / Zip Code
60607
State / Province / Region
IL
Country
US
State / Province / Region
IL
Country
US

C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site Leo
Contact - First
Name *
3. Primary Site Van Buuren
Contact - Last
Name *
4. Title Area Construction Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
1-919-931-2845
Telephone No.*
7. Organization
McDonald's USA, LLC.
Name
8. Site Contact
Street Address
Mailing Address*
110 N Carpenter St
Address Line 2
aty
Chicago
Fbstal / Zip Code
60607
9. Consultant Name (optional)
First and Last nacre
10. Consultant E- This person will be copied on all correspondence.
mail
11. Consultant
Telephone No.
State / Province / Region
IL
Country
US

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
............................................................................................................................................................
1. Date E&SC Plan 10/09/2019
Approved *
2. E&SC Plan Project Forsy-2020-008
Number/ID * Assigned by agency or local program
3. E&SC Plan F State DEQ Office
Approved by r Local Program
4. State DEQ Office * Winston-Salem (WSRO)
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 32-1699 - KERNERSVILLE - NCDEQ Grading Permit
Approval 11.51 MB
- APPROVED.pdf
letter/documentation
Mist be RDF format
6. NOI Certification NCGO1 Notice of Intent (NOI) Certification
Form 1.26MB
Form_signed.pdf
Wst be RDF format
This is an Express F No
Review Project* r Yes
h

E. Certification
North Carolina General Statute 143-215.613 (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.
* rJ 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.
* rJ 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 *
Leo VAn Buuren
Title
Area Construction Manager
Organization
McDonlad's USA, LLC.
Date *
10/14/2019

F. Tracking and COC Info
NOI Tracking No. 17135
NC Reference No. NCG01-2019-2339
Uses 'count number variable (incremrented by SP)
Certificate of NCC192339
Coverage (COC) Uses 'count nunber variable (increrrentedbySP)
No. *
Count Number 2339
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.)