NCC192885_NOI Application_20191206

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 11/21/2019 2:00:43 PM(NCG01 NOI Submission)
Approve by McCoy, Suzanne 11/21/2019 3:19:21 PM(Review-Construction NOI 18782)
• The task was assigned to McCoy,Suzanne by round robin distribution 11/21/2019 2:01 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is: November 25,2019 5:00
PM 11/21/2019 2:01 PM
Submit by McCoy, Suzanne 12/6/2019 12:28:00 PM(Payment Verification for NCC192885)
* Muslim Community Center
• McCoy,Suzanne assigned the task to McCoy, Suzanne 12/6/2019 12:27 PM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:January 2, 2020 5:00 PM
11/21/2019 3:19 PM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Eliminatio em 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIVWATER DISCHARGES associated with construction activities(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Muslim Community Center
2.County* Mecklenburg
3. Highway or Street 3316 Johnston Oehler Rd
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Charlotte
5.State* NC
6.Zip Code* 28269
7. Latitude* Enter the latitude in decimal degrees
35.3630
8. Longitude* Enter the longitude in decimal degrees(MJSTbe negative)
-80.7610
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* 11/26/2019
Estinated Construction Project Start Date
10. Date to End* 04/20/2020
Estimated Construction Project End Cute
11.SIC(Primary)* Other(0000)
Standard Industrial Classification for Ceveloprrent
12.Acres to be 7.70
disturbed* (including off-site borrow and waste areas)
13.Total site area 7.70
(acres)*
14. Post- 7.70
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-MECKL-2019-Muslim Community Center
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 Stony Creek
Wate rbody* Barre of waterbody into which storrrwater runoff will discharge
15b.Waterbody 13-17-5-5
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. ^
F2rnittee 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 Muslim Comunity Center of Charlotte
Name*
2. First Name* Syed
ff Corporation,enter Pegistered Agent First Barre
3. Last Name* Shah
ff Corporation,enter Faegistered Agent Last%rre
3b.Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 980.333.3764
Telephone No.*
6. Permittee Mailing Street Address
Address* 3116 Johnston Oehler Road
Address Line 2
City State/Frovince/Faegion
Charlotte NC
Fbstal/Zip Code Country
28269 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 3116 Johnston Oehler Road
Address Line 2
City State/Frovince/Fbgion
Charlotte NC
Fbstal/Zip Code Country
28269 us

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1.Type of Non-Government
Ownership*
2. Primary Site Brian
Contact-First
Name*
3. Primary Site Morse
Contact-Last
Name*
4.Title Project Manager
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 7045530834
Telephone No.*
7.Organization Metrolina Builders Inc.
Name
8.Site Contact Street Address
Mailing Address* 425 E Hebron St
Address Line 2
City State/Rovince/Region
Charlotte NC
Fbstal/Zip Code Country
28273 us
9. Consultant Name (Optional)
Mohammad Banawan
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 704.293.3744
Telephone No.

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 06/26/2019
Approved*
2. E&SC Plan Project LDGP-2019-00124
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 Charlotte
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 Letter of Approval modified April 2019 Muslim
Approval 27.27KB
Community Center.pdf
letter/documentation
Mast be FDFforrrat
6. NOI Certification NOI CERTIFICATION FORM Syed Shah 2019-
Form MCC.pdf 1022.09KB
Mist be RDFforrrat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66(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 knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis 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 guiltyofa Class 2 misdemeanor which mayinclude 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* Syed Shah
Title President
Organization Muslim Community Center of Charlotte
Date* 11/21/2019

F. Tracking and COC Info
NOI Tracking No. 18782
NC Reference No. NCG01-2019-2885
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC192885
Coverage (COC) Uses'count number'variable(increrrented by SP)
No.*
Count Number 2885
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2019
Year of date reviewed(used to assign YY digits after"NOC'in COCno.)