NCC200352_NOI Application_20200228

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/27/2020 8:21:24 PM (NCG01 NOI Submission)
Approve by Clark, Paul 1/28/2020 12:48:21 PM (Review- Construction NOI 21201)
• The task was assigned to Clark, Paul by round robin distribution 1/27/2020 8:21 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 29, 2020 5:00
PM 1/27/2020 8:21 PM
Submit by McCoy, Suzanne 2/28/2020 2:43:54 PM (Payment Verification for NCC200352)
* Rodger Nelms
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/28/2020 2:43 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 10, 2020 5:00 PM
1 /28/2020 12:48 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name* Starbucks
1 b. Specific Lot This field may be used to list specifc lot nunbers.
Numbers
2. County* Cumberland
3. Highway or Street Cedar Creek Road
Address* Street name only is acceptable if no address number assigned yet
4. CityorTownship* Fayetteville
5. State * NC
6. Zip Code* 28312
7. Latitude* Enter the latitude in decimal degrees
35.0100
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.8290
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*
02/14/2020
Estimated Construction Project Start Date
10. Date to End *
06/30/2020
Estinated Construction Project End late
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
1.28
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.95
(acres)*
14. Post- 0.77
construction (Estirated)
impervious area
(acres) *

NCC Project NCC-CUMBE-2020-Starbucks
Tracking ID Assignedautonatically
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 Lock Creek (near Vander)
Wate rbody* Nacre of waterbody into which storrrwater runoff w ill discharge
15b. Waterbody 18-32
Index No. * NC Waterbody Index Minter
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. ^
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 Fayetteville Cedar Creek 2019, LLC
Name *
2. First Name* Collins
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Hartzog
If Corporation, enter FZegistered Agent Last %rre
3b. Title Member/Manager
4. Permitee E-mail [e-mail]
Address *
5. Permittee 18033616718
Telephone No.*
6. Permittee Mailing Street Address
Address* 109 Still Wild Lane
Address Line 2
city State / Frovince / Faegion
Elgin SC
Fbstal / Zip Code Country
29045 United States
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
109 Still Wild Lane
Address Line 2
City
State / Frovince / Fbgion
Elgin
SC
F bstal / Zip Code
Country
29045
United States
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Information
..............................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Rodger
Contact - First
Name *
2. Primary Site Nelms
Contact - Last
Name *
3. Title Owner
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
4043147051
Telephone No.
6. Organization
CRH Construction
Name
7. Site Contact
Street Address
Mailing Address*
760 Whitney Court
Address Line 2
city
Prosper
Fbstal / Zip Code
75078-8548
8. Consultant Name
(Optional)
First and Last name
9. Consultant E-mail This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Frovince / Pegion
TX
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/26/2019
Approved *
2. E&SC Plan Project CUMBE-2020-069
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. For linear projects, please also upload a site map showing the overall extent of the project.
5. E&SC Plan
Approval
letter/documentation
Notes (Optional)
NCDEQ Letter of Approval.pdf
Wst be FDFfornat
117.75KB
Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application.
6. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form SW.pdf 119.34KB
Wst be FDFfornat
This is an Express r 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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle 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 *
Collins Hartzog
Title
Member/Manager
Organization
Fayetteville Cedar Creek 2019, LLC
Date *
01 /27/2020

F. Tracking and COC Info
NOI Tracking No. 21201
NC Reference No. NCG01-2020-0352
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200352
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 352
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.)