NCC200785_NOI Application_20200316

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/26/2020 10:09:54 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 2/26/2020 1:40:01 PM (Review- Construction NOI 22447)
• The task was assigned to Garcia, Lauren V by round robin distribution 2/26/2020 10:10 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 28, 2020 5:00
PM 2/26/2020 10:10 AM
Submit by Garcia, Lauren V 3/16/2020 9:13:13 AM (Payment Verification for NCC200785)
* City of Greensboro
• Garcia, Lauren V assigned the task to Garcia, Lauren V 3/16/2020 9:10 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: April 8, 2020 5:00 PM
2/26/2020 1:40 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
la. Project Name * Contract 2013-080, Holden Road Sidewalk Improvements
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Guilford
3. Highway or Street Holden Road - see attached
Address* Street name only is acceptable if no address nunber assigned yet
4. CityorTownship* Greensboro
5. State * NC
6. Zip Code* 27401
7. Latitude* Enter the latitude in decimal degrees
36.0711
8. Longitude * Enter the longitude in decirral degrees (MJSTbe negative)
-79.8339
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*
09/18/2020
Estinated Construction Project Start Date
10. Date to End *
07/30/2021
Estirrated Construction Project End late
11. SIC (Primary) *
Highway (1611)
Standard Industrial Classification for Development
12. Acres to be
5.98
disturbed*
(including off -site borrow and waste areas)
13. Total site area 22.12
(acres)*
14. Post- 16.07
construction (Estirrated)
impervious area
(acres) *

NCC Project NCC-GUILF-2020-Contract 2013-080, Holden Road Sidewalk
Tracking ID Improvements
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 Jordan Branch
Waterbody* N3rreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 16-11-14-1-4
Index No. * NCWaterbody Index Narrber
Stormwater F No
discharges will flow 17 Yes
to additional
wate rs *
15c. Additional North Buffalo Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 16-11-14-1
Index No. NCWaterbody Index Narrber
15e. Additional South Buffalo Creek
Receiving Waterbody narre
Waterbody
15f. Waterbody 16-11-14-2
Index No. NCWaterbody Index Narrber
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 City of Greensboro
Name * If pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name* John
IF Corporation, enter Fbgistered Agent First Barre
3. Last Name* Fersner
If Corporation, enter Faegistered Agent Last %rre
3b. Title Chief Design Engineer
4. Permitee E-mail John. [e-mail]
Address *
5. Permittee 336-373-2308
Telephone No.*
6. Permittee Mailing Street Address
Address* Post Office Box3136
Address Line 2
city State / Ftovince / Faegion
Greensboro NC
Fbstal / Zip Code Country
27402-3136 USA
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
300 West Washington Street
Address Line 2
City
State / Ffovince / Plegion
Greensboro
NC
Flostal / Zip Code
Country
27401
US
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Melinda
Contact - First
Name *
2. Primary Site
King
Contact - Last
Name *
3. Title
Supervisor Construction Inspections
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-373-2372
Telephone No.
6. Organization
City of Greensboro
Name
7. Site Contact
Street Address
Mailing Address*
Post Office Box3136
Address Line 2
city
Greensboro
Fbstal / Zip Code
27402-3136
8. Consultant Name
(Optional)
First and Last nacre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
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 02/03/2020
Approved *
2. E&SC Plan Project GUILF-2020-006
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 * Winston-Salem (WSRO)
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 or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan 2013-080_Letter_of_Approval-20200203.pdf 482.42KB
Approval letter or Contract 2013-080 Project Coordinates.pdf 222.18KB
Grading Permit
Mist be RDFforrrat
Site Map (Optional) Helpful for linear project review
Mast be FDFfornat
Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
Project coordinates list identifies the approximate center of each of
the linear projects.
6. NOI Certification 2013-080_NCG01_NOI-Signed.pdf 454.35KB
Form Mast be FDFfornat
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 *
John D. Fersner, P.E.
Title
Chief Design Engineer
Organization
City of Greensboro
Date *
02/26/2020

F. Tracking and COC Info
NOI Tracking No. 22447
NC Reference No. NCG01-2020-0785
Uses 'count number' variable (incremrented by SP)
Certificate of NCC200785
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 785
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.)