HomeMy WebLinkAboutNCC191939_NOI Application_20190919Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/17/2019 8:19:09 AM (NCG01 NOI Submission)
Approve by McCoy, Suzanne 9/18/2019 8:18:48 AM (Review- Construction NOI 15970)
• The task was assigned to McCoy, Suzanne by round robin distribution 9/17/2019 8:19 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 19, 2019 5:00
PM 9/17/2019 8:19 AM
Submit by McCoy, Suzanne 9/19/2019 8:48:26 AM (Payment Verification for NCC191939)
In Eastern Pines Fire -Rescue.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 9/19/2019 8:47 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 30, 2019 5:00 PM
9/18/2019 8:19 AM
STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Eastern Pines Fire -Rescue
2. County* Pitt
3. Highway or Street 5453 Eastern Pines Road Greenville, NC 27858
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Chicod
5. State * NC
1 r-i) iTiT 7i1) M 1i1 f_T1II a 10141
6. Zip Code* 27858
7. Latitude * Enter the latitude in decirral degrees
35.5540
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-77.2996
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 *
01 /06/2020
Estimated Construction Project Start Date
10. Date to End*
12/18/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Other (0000)
Standard Industrial aassification for Development
12. Acres to be
3.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area
3.62
(acres)*
14. Post-
2.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-PITT-2020-Eastern Pines Fire -Rescue
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. Please
enter only immediate receiving waterbodies - not waters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving Juniper Branch
Wate rbody* Barre of waterbody into which stormuater runoff will discharge
15b. Waterbody 28-101-6
Index No.* NC Waterbody Index Narrber
Stormwater W No
discharges will flow F Yes
to additional
wate rs *
16a. Is this project F 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 Eastern Pines Fire -Rescue, Inc.
Name *
2. First Name* Robert
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Milam
ff Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail MilamR@fnb-corp.com
Address*
5. Permittee 252-321-3012
Telephone No.*
6. Permittee Mailing Street Address
Address* 5453 Eastern Pines Road
Address Line 2
City
Greenville
Postal / Zip Code
27858-9574
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
5453 Eastern Pines Road
Address Line 2
City
Greenville
Rastal / Zip Code
27858-9574
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us
C. Site Contact Information
Part C.
Proiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Igor
Contact - First
Name *
3. Primary Site Palyvoda
Contact - Last
Name *
4. Title Vice President
5. Site Contact E- ipalyvoda@baldWndesignconsultants.com
mail Address*
6. Site Contact 252-756-1390
Telephone No.*
7. Organization Baldwin Design Consultants, PA
Name
8. Site Contact Street Address
Mailing Address* 1700-D East Arlington Boulevard
Address Line 2
city
Greenville
Pbstal / Zip Code
27858
9. Consultant Name (optional)
Igor Palyvoda
First and Last name
10. Consultant E- ipalyvoda@baldvvindesignconsultants.com
mail This person will be copied on all correspondence.
11. Consultant 252-756-1390
Telephone No.
State / Province / Region
NC
Country
us
D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 09/11/2019
Approved *
2. E&SC Plan Project PC SESC 2019-7
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Pitt County
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 Eastern Pines Fire Rescue conditional approval
Approval 115.86KB
letter.pdf
letter/documentation
Mist be RJF format
6. NOI Certification Signed NCG01 Notice of Intent Certification
Form 32.94KB
Form.pdf
Mast be RCF format
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 electronically signs this Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized responsible
person within the same organization as the Permittee. *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
t�m- e lI-r
Type Name* Robert Milam
Title President
Organization Eastern Pines Fire -Rescue, Inc.
Date * 09/17/2019
F. Tracking and COC Info
NOI Tracking No. 15970
NC Reference No. NCG01-2019-1939
Uses 'count number variable (incremented by SP)
Certificate of NCC191939
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 1939
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.)