NCC200440_NOI Application_20200205

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/4/2020 9:33:18 AM (NCG01 NOI Submission)
Approve by Clark, Paul 2/4/2020 9:42:18 AM (Review- Construction NOI 21477)
• The task was assigned to Clark, Paul by round robin distribution 2/4/2020 9:33 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 6, 2020 5:00
PM. The priority is: High 2/4/2020 9:33 AM
Submit by McCoy, Suzanne 2/5/2020 7:15:41 AM (Payment Verification for NCC200440)
* James G Tart
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/5/2020 7:15 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 17, 2020 5:00 PM.
The priority is: High 2/4/2020 9:42 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name * Building Addition, Hog Slat, Inc, Clinton, NC Plastic Plant
2. County* Sampson
3. Highway or Street 160 Five Bridge Road
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Clinton
5. State * NC
6. Zip Code * 28328
7. Latitude * Enter the latitude in decimal degrees
35.0162
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-78.3473
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*
12/31/2021
Estimated Construction Project End Cute
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Developrrent
12. Acres to be
16.09
disturbed*
(including off -site borrow and waste areas)
13. Total site area
48.11
(acres) *
14. Post-
18.53
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-SAMPS-2019-Building Addition, Hog Slat, Inc, Clinton, NC
Tracking ID
Plastic Plant
Assigned automatically

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 Williams Old Mill Branch (Mill Branch)
Waterbody* Name of waterbody into which storrrwater runoff will discharge
15b. Waterbody 18-68-1-10
Index No.* NCWaterbody Index Nurrber
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. ^
Flarnittee 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 HS Investments, LLC
Name *
2. First Name* Glenn
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Tart
If Corporation, enter F3egistered Agent Last %rre
3b. Title Construction Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 919-934-7788
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box300
Address Line 2
city
State / F rovince / Faegion
Newton Grove
NC
Fbstal / Zip Code
Country
28366
USA
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
PO Box300
Address Line 2
City
State / Frovince / Fbgion
Newton Grove
NC
Fbstal / Zip Code
Country
28366
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Glenn
Contact - First
Name *
2. Primary Site
Tart
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
919-934-7788
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
PO Box300
Address Line 2
city
Newton Grove
Fbstal / Zip Code
28366
8. Consultant Name
(Optional)
Lauren Granger
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
919-577-1080
Telephone No.
State / Rovince / Region
NC
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 10/29/2019
Approved *
2. E&SC Plan Project SAMPS-2020-003
Number/ID * Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. State DEQ Office * Fayetteville (FRO)
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 samps-2020-003.pdf
Approval Wst be FDFfornat
letter/documentation
80.47KB
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification 20200203145459.pdf 88.53KB
Form Mast be FDFformat
This is an Express f No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E (i) 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 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 *
Glenn Tart
Title
Construction Manager
Organization
Hog Slat
Date *
02/04/2020

F. Tracking and COC Info
NOI Tracking No. 21477
NC Reference No. NCG01-2020-0440
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200440
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 440
Sequential number for submittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)