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HomeMy WebLinkAboutNCC192869_NOI Application_20191202Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 11/18/2019 1:58:58 PM (NCG01 NOI Submission) Approve by Garcia, Lauren V 11/20/2019 6:04:58 PM (Review- Construction NOI 18583) Reviewer corrected the index from 17-(3.3) to 13-2-(0.5). • The task was assigned to Garcia, Lauren V by round robin distribution 11/18/2019 1:59 PM The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 20, 2019 5:00 PM 11/18/2019 1:59 PM Subnut by McCoy, Suzanne 12/2/2019 12:50:17 PM (Payment Verification for NCC192869) * Future Foam inc. • McCoy, Suzanne assigned the task to McCoy, Suzanne 12/2/2019 12:49 PM The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 1, 2020 5:00 PM 11 /20/2019 6:05 PM .• SThF� '; 1 NORTH CAROLINA EnrlronmertW quallly A. Project Information Part A. Project Location and Waterbody Information 1. Project Name * Future Foam Building Expansion - Lot Grading 2. County* Guilford 3. Highway or Street 1300 Prospect Street Address * Street narre only is acceptable if no address number assigned yet 4. City or Township* High Point 5. State * NC 6. Zip Code * 27260 7. Latitude * Enter the latitude in decimal degrees 35.9270 8. Longitude* Enter the longitude in decimal degrees (M. ST be negative) -80.0239 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* 12/01/2019 Estimated Construction Project Start Date 10. Date to End* 01/31/2020 Estimated Construction Project End Cute 11. SIC (Primary)* Commercial (1542) Standard Industrial aassification for Developrrent 12. Acres to be 8.72 disturbed* (including off -site borrow and waste areas) 13. Total site area 27.03 (acres) * 14. Post- 17.00 construction (Estimated) impervious area (acres) * NCC Project NCC-GUILF-2019-Future Foam Building Expansion - Lot Grading Tracking ID Assigned autorTatically 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 Lkvfiarrie River Wate rbody* Barre of waterbody into which storrrwater runoff will discharge 15b. Waterbody 13-2-(0.5) Index No.* NCWaterbody Index Ninber Stormwater V No discharges will flow r 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. ^ Fternittee Inforrration - Legally Fbsponsible 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 Future Foam, Incorporated Name * 2. First Name* Patrick IF Corporation, enter Fbgistered Agent First Barre 3. Last Name* Medinger IF Corporation, enter FZegistered Agent Last %rre 3b. Title CFO/Secretary 4. Permitee E-mail pmedinger@futurefoam.com Address * 5. Permittee 402.658.5609 Telephone No.* 6. Permittee Mailing Street Address Address* P.O. Box 1107 Address Line 2 City State / Frovince / Faegion Omaha NE Fbstal / Zip Code Country 68101 USA Check box if the r Yes street address the same as mailing address 7. Permittee Street Street Address Address* 1610 Avenue N Address Line 2 City State / Frovince / Fbgion Council Bluffs IA Fbstal / Zip Code Country 51501 US C. Site Contact Information Part C. Roject Site Contact Inforrration _................................................................................................................................................._ 1. Type of Non -Government Ownership * 2. Primary Site Tim Contact - First Name * 3. Primary Site Akins Contact - Last Name * 4. Title Plant Manager 5. Site Contact E- takins@futurefoam.com mail Address* 6. Site Contact 336.442.5336 Telephone No.* 7. Organization Future Foam, Inc Name 8. Site Contact Street Address Mailing Address* 1300 Prospect Street Address Line 2 City High Point Fbstal / Zip Code 27260-8329 9. Consultant Name (Optional) Lesley England First and Last narre 10. Consultant E- lengland@dmp-inc.com mail This person will be copied on all correspondence. 11. Consultant 336.819.5274 Telephone No. State / Rovince / Fbgion NC Country us D. E&SC Plan Part D. ^ Erosion & Sediment Control (E&SC) Ran Approval Information ...................................................................................................................................................................................................................................................................................................................................... 1. Date E&SC Plan 11/15/2019 Approved * 2. E&SC Plan Project EN1903402290 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 High Point 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 LOA EN1903402290 11-13-2019.pdf 5.04MB Approval Wst be RDFfornat letter/documentation 6. NOI Certification NCG01.pdf 1.12MB Form Mist be R7Ffon-rat This is an Express F No Review Project* r Yes E. Certification North Carolina General Statute 143-215.66 (1) provides that: Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Artcle; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Artcle shall be guilty ofa Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). Under penalty of law, I certify that: 17 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. * 17 I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control Plan. * rJ 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. * 17 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 f 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 Type Name* Patrick Medinger Title CFO/Secretary Organization Future Foam, Incorporated Date * 11 /18/2019 F. Tracking and COC Info NOI Tracking No. 18583 NC Reference No. NCG01-2019-2869 Uses 'count number' variable (incremrented by SP) Certificate of NCC192869 Coverage (COC) Uses 'count number' variable (incremented by SP) No.* Count Number 2869 Sequential number for submittal that is incremented by Stored Frocedure COC Year 2019 Year of date reviewed (used to assign YY digits after "NOC' in COCno.)