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Home My WebLink AboutNCC190677_NOI Application_20190619 Action History (UTC-05:00) Eastern Time(US&Canada) Submit by Anonymous User 6/19/2019 3:54:28 PM(NCG01 NOI Submission) Approve by Morman,Alaina 6/20/2019 3:35:29 PM(Review-Construction NOI 12568) • The task was assigned to Morman,Alaina by round robin distribution 6/19/2019 3:54 PM • The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:June 21,2019 5:00 PM 6/19/2019 3:54 PM Submit by Morman,Alaina 6/20/2019 3:36:36 PM(Payment Verification-NCG01-2019-0677) • The task was assigned to Morman,Alaina.The due date is:June 21,2019 5:00 PM 6/20/2019 3:35 PM 1 sees �' � ••. -• i •• i i• i IY sell NORTH CAROLINA Environmental QUII A. Project Information Part A. Project Location and Waterbody Information 1. Project Name* Rough Horn Swamp(I and 11)Restoration Site 2. County* Columbus 3. Highway or Street CCC Road Address* Street narra only is acceptable if no address nurrber assigned yet 4. City or Township* Evergreen 5. State* INC 6.Zip Code* 28438 7. Latitude* Enter the latitude in decirral degrees 34.4478 8. Longitude* Enter the longitude in decirral degrees(MJSTbe negative) -78.9392 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* 07/01/2019 Estimated Construction Project Start Date 10. Date to End* 10/01/2019 Estimated Construction Project End Date 11. SIC(Primary)* Other(0000) Standard Industrial aassification for Developrrent 12.Acres to be 75.93 disturbed* (including off-site borrow and waste areas) 13.Total site area 223.00 (acres)* 14. Post- 0.00 construction (Estimated) impervious area (acres)* NCC Project NCC-COLUM-2019-Rough Horn Swamp(I and 11) Restoration Site 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. You may enter up to 3 waterbodies. 15a. Receiving Lumber River Wate rbody* Nacre of waterbody into which stormuater runoff will discharge 15b.Waterbody 14-(13) 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 ..................................................................................................................................................................... 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 KCI Technologies Inc. Name* 2. First Name* Timothy ff Corporation,enter Registered Agent First l\b e 3. Last Name* Morris ff Corporation,enter Registered Agent Last Barre 3b.Title Senior Associate 4. Permitee E-mail tim.morris@kci.com Address* 5. Permittee 919-278-2511 Telephone No.* 6. Permittee Mailing Street Address Address* 4505 Falls of Neuse Road Address Line 2 City State/Province/Region Raleigh NC Postal/Zip Code Country 27609-2512 us Check box if the rJ Yes street address the same as mailing address 7. Permittee Street Street Address Address* 4505 Falls of Neuse Road Address Line 2 City State/Province/Region Raleigh NC Pastal/Zip Code Country 27609-2512 US C. Site Contact Information Part C. Project Site Contact Inforrration ............................................................................................. 1.Type of Individual Ownership* 2. Primary Site Timothy Contact-First Name* 3.Primary Site Morris Contact-Last Name* 4.Title Senior Associate 5.Site Contact E- tim.morris@kci.com mail Address* 6.Site Contact 919-278-2511 Telephone No.* 7.Organization KCI Technologies Inc. Name 8.Site Contact Street Address Mailing Address* 4505 Falls of Neuse Road Address Line 2 City State/Province/Region Raleigh NC Rbstal/Zip Code Country 27609-2512 us D. E&SC Plan Part D. Erosion&Sediment Control(E&SC)Ran Approval Information ....................................................................................................................................................................................................................................... ............................................................................................. 1. Date E&SC Plan 06/17/2019 Approved* 2. E&SC Plan Project COLUM-2019-011 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* Wilmington(WiRO) 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 COLUM-2019-011 Approval 06-17-2019.pdf 307.29KB Approval Mist be PDF format letter/documentation 6. NOI Certification NCG01-eNO1-Certification-Form-20190507-DEMLR- Form SW.pdf 227.93KB Wst be FDFforrrat 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 � 'r '!r'r 7f fiif Type Name* Timothy J. Morris Title Senior Associate Organization KCI Technologies Inc. Date* 06/19/2019 F. Tracking and COC Info NOI Tracking No. 12568 NC Reference No. NCG01-2019-0677 Uses'count_nunber variable(incremented by SP) Certificate of NCC190677 Coverage (COC) Uses'count_nunber'variable(incremented by SF) No.* Count Number 677 Sequential nunber for subrrittal that is increrrented by Stored Procedure COC Year 2019 Year of date reviewed(used to assign YY digits after"NGC'in OOCno.)