NCC192915_NOI Application_20191126

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/22/2019 4:03:28 PM (NCG01 NOI Submission)
Approve by Clark, Paul 11/25/2019 9:11:06 AM (Review- Construction NOI 18835)
• Georgoulias, Bethany reassigned the task to Clark, Paul 11/25/2019 7:59 AM
• The task was assigned to Garcia, Lauren V by round robin distribution 11/22/2019 4:03 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 26, 2019 5:00
PM 11/22/2019 4:03 PM
Submit by McCoy, Suzanne 11/26/2019 7:11:45 AM (Payment Verification for NCC192915)
* Jonathan Renfroe
• McCoy, Suzanne assigned the task to McCoy, Suzanne 11/26/2019 7:11 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 6, 2020 5:00 PM
11/25/2019 9:11 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Car Wash - Roanoke Rapids, NC
2. County* Halifax
3. Highway or Street Julian R. Allsbrook Hwy
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Roanoke Rapids
5. State * TN
6. Zip Code * 27870
7. Latitude * Enter the latitude in decimal degrees
36.4352
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-77.6390
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*
12/14/2019
Estimated Construction Project Start Date
10. Date to End*
05/12/2019
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
1.10
disturbed*
(including off -site borrow and waste areas)
13. Total site area
1.22
(acres) *
14. Post-
0.66
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-HALIF-2019-Car Wash - Roanoke Rapids, INC
Tracking ID
Assigned autorTatically

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 Chockoyotte Creek
Wate rbody* arm of waterbody into which storrrwater runoff will discharge
15b. Waterbody 23-29
Index No.* NCWaterbody Index Nirrber
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
Fternittee Inforrration - Legally Fbsponsible Entity and Individual
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 Hutton ST 17, LLC
Name *
2. First Name* Karen
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Hutton
If Corporation, enter Registered Agent Last %rre
3b. Title President & CEO
4. Permitee E-mail [e-mail]
Address *
5. Permittee 423-400-1993
Telephone No.*
6. Permittee Mailing Street Address
Address* 736 Cherry Street
Address Line 2
city State / Frovince / Region
Chattanooga TN
Postal / Zip Code Country
37402-1909 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 736 Cherry Street
Address Line 2
City
State / Frovince / Fbgion
Chattanooga
TN
Fbstal / Zip Code
Country
37402-1909
US

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Type of
Non -Government
Ownership *
2. Primary Site
Scott
Contact - First
Name *
3. Primary Site
Mitchell
Contact - Last
Name *
4. Title
Project Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
7069801281
Telephone No.*
7.Organization
Hutton
Name
8. Site Contact
Street Address
Mailing Address*
2525 Broad Street
Address Line 2
City
Chattanooga
Fbstal / Zip Code
37408
9. Consultant Name
(Optional)
Jonathan Renfroe
First and Last narre
10. Consultant E-
[e-mail]
mail
This person will be copied on all correspondence.
11. Consultant
423-463-6105
Telephone No.
State / Rovince / Fbgion
TN
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/14/2019
Approved *
2. E&SC Plan Project HALIF-2020-005
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Raleigh (RRO)
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 Roanoke Rapids, NC_Julian R. Allsbrook
Approval 59.94KB
Hwy. —Letter of Approval.pdf
letter/documentation
Mast be R7Ffon-rat
6. NOI Certification 201911221056.pdf 292.11KB
Form Mist be PDFfon-rat
This is an Express F No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) provides that:
Any person who knowingly makes anyfalse 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 Artcle; 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 Artcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
17 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.
* 17 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
Cd ['l. `itfi411-`4W!
Type Name * Karen J. Hutton
Title President & CEO
Organization Hutton ST 17 LLC
Date * 11 /22/2019

F. Tracking and COC Info
NOI Tracking No. 18835
NC Reference No. NCG01-2019-2915
Uses 'count number' variable (incremrented by SP)
Certificate of NCC192915
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2915
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)