NCC202110_NOI Application_20200601

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/19/2020 10:51:22 AM (NCG01 NOI Submission)
Approve by Clark, Paul 5/19/2020 2:49:12 PM (Review- Construction NOI 25813)
• Morman, Alaina reassigned the task to Clark, Paul 5/19/2020 12:49 PM
* This one's for you, Paul.-)
• The task was assigned to Morman, Alaina by round robin distribution 5/19/2020 10:51 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: May 21, 2020 5:00 PM
5/19/2020 10:51 AM
Submit by Garcia, Lauren V 6/1/2020 2:44:05 PM (Payment Verification for NCC202110)
* City of Greensboro
• Garcia, Lauren V assigned the task to Garcia, Lauren V 6/1/2020 2:42 PM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: June 30, 2020 5:00 PM
5/19/2020 2:49 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting r No
an NOI that was r Yes
rejected before?
Previous Rejected 25591
NOI No.
Prior Reviewer Paul Clark
Name
1a. Project Name * Spencer Love Tennis Complex Ph.2
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Guilford
3. Highway or Street 3802 Jaycee Park Dr.
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Greensboro
5. State * NC
6. Zip Code * 27455
7. Latitude * Enter the latitude in decimal degrees
36.1202
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-79.8353
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* 07/01/2020
Estimated Construction Project Start Date
10. Date to End* 05/01 /2022
Estimated Construction Project End Cute
11. SIC (Primary) * Other (9999)
Standard Industrial Classification for Ceveloprrent

12. Acres to be 3.66
disturbed* (including off -site borrow and waste areas)
13. Total site area 343.60
(acres) *
14. Post- 14.35
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-GUILF-2020-Spencer Love Tennis Complex Ph.2
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 Richland Creek
Wate rbody* %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 16-11-7-(1)
Index No.* NCWaterbody Index Nurrber
Stormwater rJ 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. ^
Fl rnittee 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
Legally Responsible Entity
Name *
City of Greensboro
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Shawna
IF Corporation, enter Faegistered Agent First %rre
3. Last Name*
Tillery
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Planning and Project Development Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336-373-2489
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box3136
Address Line 2
Cty
Greensboro
Fbstal / Zip Code
27402
Check box if the F Yes
street address the
same as mailing
address
State / Frovince / Pbegion
NC
Country
USA
7. Permittee Street
Street Address
Address*
1001 Fourth St.
Address Line 2
city
State / Province / Region
Greensboro
NC
Postal / Zip Code
Country
27402
USA
8. Type of
Government - Municipal
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Shawna
Contact - First
Name *
2. Primary Site
Tillery
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
336-373-7808
Telephone No.
6. Organization
Name
7. Site Contact
Street Address
Mailing Address*
PO Box3136
Address Line 2
city
Greensboro
Fbstal / Zip Code
27402
8. Consultant Name
(Optional)
Tori Small
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
3363101481
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 05/07/2020
Approved *
2. E&SC Plan Project GUILF-2020-029
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 D00051320-05132020134137.pdf 972.99KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) Mast be FCFfornat. Rease do not upload entire set of E&SCplans.
7. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies for linear projects if necessary.
8. NOI Certification D00051920-05192020104639.pdf 57.37KB
Form Mist be RDFfornat
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 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
u�%x��r• c �'�1�is�
Type Name * Shawna tillery
Title Planning & Development Division Manager
Organization Legally Responsible Entity
City of Greensboro
Date * 05/19/2020

F. Tracking and COC Info
NOI Tracking No. 25813
NC Reference No. NCG01-2020-2110
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202110
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2110
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.)