NCC191259_NOI Application_20190814

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/7/2019 8:45:34 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 8/7/2019 9:37:57 AM (Review- Construction NOI 14553)
• The task was assigned to McCoy, Suzanne by round robin distribution 8/7/2019 8:45 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 9, 2019 5:00
PM 8/7/2019 8:45 AM
Submit by McCoy, Suzanne 8/14/2019 1:48:37 PM (Payment Verification for NCC191259)
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/14/2019 1:48 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: August 21, 2019 5:00 PM
8/7/2019 9:38 AM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * ADUSA DC-9 Freezer Expansion
2. County* Granville
3. Highway or Street 1703 East D Street
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Butner
5. State * NC
1 r-i) iTiT 7i1) M 1i1 f_TiI a 10141
6. Zip Code* 27509
7. Latitude * Enter the latitude in decirral degrees
36.1583
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-78.7319
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* 06/10/2019
Estimated Construction Project Start Date
10. Date to End* 09/30/2020
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 10.80
disturbed* (including off -site borrow and waste areas)
13. Total site area
113.76
(acres)*
14. Post-
43.92
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-GRANV-2019-ADUSA DC-9 Freezer Expansion
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 Picture Creek
Waterbody * Narre of waterbody into which stormuater runoff will discharge
15b. Waterbody 27-4-7-(2)
Index No. * NCWaterbody Index Nanber
Stormwater r No
discharges will flow rj Yes
to additional
wate rs *
15c. Additional Knap of Reeds Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 27-4-(6)
Index No. NCWaterbody Index Ninber
15e. Additional Falls Lake
Receiving Waterbody narre
Waterbody
15f. Waterbody NCWaterbody Index Nunter
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
.....................................................................................................................................................................
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 Delhaize America, Inc.
Name *
2. First Name* Dan
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Molihan
ff Corporation, enter Registered Agent Last Barre
3b. Title Director of Operations
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9195755201
Telephone No.*
6. Permittee Mailing Street Address
Address* 1703 East D Street
Address Line 2
City
Butner
Postal / Zip Code
27509
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
1703 East D Street
Address Line 2
City
Butner
Fbstal / Zip Code
27509
State / Province / Region
NC
Country
United States
State / Province / Region
NC
Country
United States

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Dan
Contact - First
Name *
3. Primary Site Molihan
Contact - Last
Name *
4. Title Director of Operations
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
919-575-5201
Telephone No.*
7. Organization
Delhaize America, Inc
Name
8. Site Contact
Street Address
Mailing Address*
1703 East D Street
Address Line 2
city
Butner
Fbstal / Zip Code
27509
State / Province / Region
NC
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 05/31/2019
Approved *
2. E&SC Plan Project Granv-2019-012
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 * 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 GRAW-2019-012 LOA MOD 20190531.pdf 73.3KB
Approval Mist be RDF format
letter/documentation
6. NOI Certification 4680_001.pdf 69.24KB
Form Mist be RDFformat
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 * Donald Molihan
Title Director of Distribution - DC 9
Organization ADUSA, LLC
Date * 08/07/2019

F. Tracking and COC Info
NOI Tracking No. 14553
NC Reference No. NCG01-2019-1259
Uses 'count number variable (incremrented by SP)
Certificate of NCC191259
Coverage (COC) Uses 'count nunber variable (increrrentedbySP)
No. *
Count Number 1259
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.)