NCC190823_NOI Application_20190702

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 7/2/2019 9:37:43 AM(NCG01 NOI Submission)
Approve by Morman,Alaina 7/2/2019 4:45:17 PM(Review-Construction NOI 12999)
• The task was assigned to Morman,Alaina by round robin distribution 7/2/2019 9:37 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 4,2019 5:00 PM
7/2/2019 9:37 AM
Submit by Morman,Alaina 7/2/2019 4:47:02 PM(Payment Verification-NCG01-2019-0823)
• The task was assigned to Morman,Alaina.The due date is:July 3,2019 5:00 PM 7/2/2019 4:45 PM

1 sees �' � ••. -• i •• i i• i
IY sell
NORTH CAROLINA
Ernvlronmental QUII
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Verizon Wireless HWY_218 Cell Site
2. County* Anson
3. Highway or Street 5853 NC 218
Address* Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* Peachland
5. State* NC
6.Zip Code* 28133
7. Latitude* Enter the latitude in decirral degrees
35.0601
8. Longitude* Enter the longitude in decirral degrees(MIST be negative)
-80.2767
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* 07/08/2019
Estimated Construction Project Start Date
10. Date to End* 08/15/2019
Estimated Construction Project End Date
11. SIC(Primary)* Commercial(1542)
Standard Industrial gassification for Developrrant
12.Acres to be 1.74
disturbed* (including off-site borrow and waste areas)
13.Total site area 27.00
(acres)*
14. Post- 1.14
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-ANSON-2019-Verizon Wireless HWY_218 Cell 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 Cribbs Creek
Waterbody* Nhrre of waterbody into which stormuater runoff will discharge
15b.Waterbody 13-17-37
Index No.* NCWaterbody Index Pbnber
Stormwater r No
discharges will flow rj Yes
to additional
wate rs*
15c.Additional Flag Branch
Receiving Waterbody nacre
Waterbody
15d.Waterbody 13-17-40-18-1
Index No. NCWaterbody Index Ninber
15e.Additional Waterbody narre
Receiving
Waterbody
15f.Waterbody NCWaterbody Index Nan-ber
Index No.
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 Southern Towers, LP
Name*
2. First Name* David
ff Corporation,enter Registered Agent First l\b e
3. Last Name* Hodder
ff Corporation,enter Registered Agent Last Barre
3b.Title Director of Site Development
4. Permitee E-mail [e-mail]
Address*
5. Permittee 423-531-6300 ext: 11
Telephone No.*
6. Permittee Mailing Street Address
Address* 250 Signal Mountain Road
Address Line 2
Suite B
City State/Province/Region
Chattanooga TN
Postal/Zip Code Country
37405-1914 us
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 250 Signal Mountain Road
Address Line 2
Suite B
City State/Province/Region
Chattanooga TN
Pastal/Zip Code Country
37405-1914 us

C. Site Contact Information
Part C.
Roject Site Contact Information
....................................................................................................................
1.Type of Non-Government
Ownership*
2. Primary Site David
Contact-First
Name*
3.Primary Site Hodder
Contact-Last
Name*
4.Title Director of Site Development
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 423-531-6300 e)d: 11
Telephone No.*
7.Organization Southern Towers, LP
Name
8.Site Contact Street Address
Mailing Address* 250 Signal Mountain Road
Address Line 2
Suite B
City State/Rovince/Region
Chattanooga Tennessee
Rbstal/Zip Code Country
37405 United States

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... ..............................................................................................
1. Date E&SC Plan 06/28/2019
Approved*
2. E&SC Plan Project ANSON-2019-007
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* Fayetteville(FRO)
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 NC-014_Hyw 218_Letter of Approval With
Approval 78.09KB
Modifications_06-28-19.pdf
letter/documentation
Mast be RDF forrrat
6. NOI Certification NC-014_Hwy 218_Signed NCG01 Notice of Intent
Form 62.77KB
(NOI)Certification Form_07-01-19.pdf
Mast be ROF format
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* David Hodder
Title Director of Site Development
Organization Southern Towers, LP
Date* 07/02/2019

F. Tracking and COC Info
NOI Tracking No. 12999
NC Reference No. NCG01-2019-0823
Uses'count number variable(incremented by SP)
Certificate of NCC190823
Coverage (COC) Uses'count number variable(increrrentedbySP)
No.*
Count Number 823
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.)