HomeMy WebLinkAboutNCC191730_NOI Application_20190906Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/4/2019 3:53:27 PM (NCG01 NOI Submission)
Approve by Morman, Alaina 9/5/2019 9:48:10 AM (Review- Construction NOI 15567)
• The task was assigned to Morman, Alaina by round robin distribution 9/4/2019 3:53 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 6, 2019 5:00
PM 9/4/2019 3:53 PM
Submit by McCoy, Suzanne 9/6/2019 10:51:02 AM (Payment Verification for NCC191730)
* T Kalesperis
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/6/2019 10:50 AM
• Georgoulias, Bethany changed the task's due date to October 5, 2019 5:00 PM 9/5/2019 12:56 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 17, 2019 5:00 PM
9/5/2019 9:48 AM
STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * 309 Navajo Drive
2. County* Randolph
3. Highway or Street 309 Navajo Drive
Address * Street name only is acceptable if no address nurrber assigned yet
4. City or Township* Archdale
5. State * NC
1 r-i) iTiT 7i) M fiIi f_TiI a 10141
6. Zip Code* 27263
7. Latitude * Enter the latitude in decirral degrees
35.8956
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-79.9570
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* 09/03/2019
Estimated Construction Project Start Date
10. Date to End* 09/30/2019
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 1.58
disturbed* (including off -site borrow and waste areas)
13. Total site area
4.50
(acres)*
14. Post-
0.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-RANDO-2019-309 Navajo Drive
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 Muddy Creek
Wate rbody* Narre of waterbody into which stormuater runoff will discharge
15b. Waterbody 17-9-(1)
Index No. * NCWaterbody Index Number
Stormwater V 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
.....................................................................................................................................................................
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 101 INC
Name *
2. First Name* Todd
ff Corporation, enter Registered Agent First Nacre
3. Last Name * Kalesperis
ff Corporation, enter Registered Agent Last Nbrre
3b. Title VP Operations
4. Permitee E-mail tk@101-inc.com
Address*
5. Permittee 765-778-1101
Telephone No.*
6. Permittee Mailing Street Address
Address* 4791 W 900 S
Address Line 2
City
State / Province / Region
Pendleton
IN
Postal / Zip Code
Country
46064
USA
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 304 Navajo Drive
Address Line 2
City
State / Province / Region
Archdale
NC
Postal / Zip Code
Country
27263-3251
USA
C. Site Contact Information
Part C.
Roiect Site Contact hforrration
1. Type of Individual
Ownership*
2. Primary Site Todd
Contact - First
Name *
3. Primary Site Kalesperis
Contact - Last
Name *
4. Title VP Operations
5. Site Contact E-
tk@101-inc.com
mail Address*
6. Site Contact
765-264-0945
Telephone No.*
7.Organization
101 INC
Name
8. Site Contact
Street Address
Mailing Address*
304 Navajo Drive
Address Line 2
city
Archdale
R>stal / Zip Code
27263
9. Consultant Name (optional)
First and Last narre
10. Consultant E- This person will be copied on all correspondence.
mail
11. Consultant
Telephone No.
State / Province / Region
NC
Country
USA
D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 08/28/2019
Approved *
2. E&SC Plan Project COA-2020-007
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* City of Archdale
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 doc00139120190828135517.pdf 985.52KB
Approval Mist be FDFforrret
letter/documentation
6. NOI Certification doc00139220190828135530.pdf 468.69KB
Form Mist be RDFformst
This is an Express r No
Review Project* r Yes
E. Certification
North Carolina General Statute 143-215.6B (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.
* V 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.
* V If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit, I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* I7 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*
Todd Kalesperis
Title
VP Operations
Organization
101 INC
Date *
09/04/2019
F. Tracking and COC Info
NOI Tracking No. 15567
NC Reference No. NCG01-2019-1730
Uses 'count number variable (incremrented by SP)
Certificate of NCC191730
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1730
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.)