HomeMy WebLinkAboutNCC190451_NOI Application_20190603 Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 6/3/2019 2:35:02 PM(NCG01 NOI Submission)
Approve by Morman,Alaina 6/4/2019 11:55:37 AM(Review-Construction NOI 11655)
• The task was assigned to Morman,Alaina by round robin distribution 6/3/2019 2:35 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:June 5,2019 5:00 PM
6/3/2019 2:35 PM
Submit by Morman,Alaina 6/4/2019 11:56:22 AM(Payment Verification-NCG01-2019-0451)
• The task was assigned to Morman,Alaina.The due date is:June 5,2019 5:00 PM 6/4/2019 11:55 AM
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NORTH CAROLINA
Ernvlronmental QUII
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Contract 2018-020, Summit Avenue Streetscape Improvements
2. County* Guilford
3. Highway or Street Summit Avenue
Address* Street narre only is acceptable if no address nurrber assigned yet
4. City or Township* Greensboro
5. State* NC
6.Zip Code* 27401
7. Latitude* Enter the latitude in decirral degrees
36.0807
8. Longitude* Enter the longitude in decirral degrees(WISTbe negative)
-79.7803
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* 10/28/2019
Estimated Construction Project Start Date
10. Date to End* 08/23/2020
Estimated Construction Project End Date
11. SIC(Primary)* Highway(1611)
Standard Industrial aassification for Developrrent
12.Acres to be 1.20
disturbed* (including off-site borrow and waste areas)
13.Total site area 6.96
(acres)*
14. Post- 5.88
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-GUILF-2019-Contract 2018-020, Summit Avenue Streetscape
Tracking ID Improvements
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. You may
enter up to 3 waterbodies.
15a.Receiving Muddy Creek
Waterbody* %rre of waterbody into which stormuater runoff will discharge
15b.Waterbody 16-11-14-1-3
Index No.* NC Waterbody Index Narrber
Stormwater No
discharges will flow Yes
to additional
wate rs*
16a.Is this project r Yes
subject to the NC f No, not subject to NC SPCA
Sediment Pollution
Control Act?*
B. Permittee Information
Part B.
Perrrittee 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 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 City of greensboro
Name*
2. First Name* Ted
ff Corporation,enter Registered Agent First l\brre
3. Last Name* Kallam
ff Corporation,enter Registered Agent Last Barre
3b.Title Engineering Division Manager
4. Permitee E-mail Ted.Kallam@greensboro-nc.gov
Address*
5. Permittee (336)373-2302
Telephone No.*
6. Permittee Mailing Street Address
Address* Post Office Box3136
Address Line 2
City State/Province/Region
Greensboro NC
Postal/Zip Code Country
27402-3136 USA
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 300 West Washington Street
Address Line 2
City State/Province/Region
Greensboro NC
Postal/Zip Code Country
27401 USA
C. Site Contact Information
Part C.
Project Site Contact Information
...............................................................................................
1.Type of Government- Municipal
Ownership*
2. Primary Site Melinda
Contact-First
Name*
3.Primary Site King
Contact-Last
Name*
4.Title Supervisor Construction Inspections
5.Site Contact E- Melinda.King@greensboro-nc.gov
mail Address*
6.Site Contact (336)373-2372
Telephone No.*
7.Organization City of Greensboro
Name
8.Site Contact Street Address
Mailing Address* Post Office Box3136
Address Line 2
oty State/Province/Region
Greensboro NC
Fbstal/Zip Code Country
27402-3136 USA
D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 04/03/2019
Approved*
2. E&SC Plan Project GUILF-2019-030
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 2018-020_Letter of Approval.pdf 2.1 MB
Approval Mist be R7Fforrrat
letter/documentation
6. NOI Certification 2018-020_NCG01-eNO1-Certification-Signed.pdf 907.55KB
Form Mist be RDF forr at
This is an Express f•No
Review Project* r Yes
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 signs this Certification above and signs the NOI Certification Form should be the same
person(or authorized responsible person within the same organization)as listed in Section B(Permittee Information)
of this form. *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* Ted Kallam
Title Engineering Division Manager
Organization City of Greensboro
Date* 06/03/2019
F. Tracking and COC Info
NOI Tracking No. 11655
NC Reference No. NCG01-2019-0451
Uses'count number variable(incremented by SP)
Certificate of NCC190451
Coverage (COC) Uses'count_nunber'variable(incremrented by SF)
No.*
Count Number 451
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.)