NCC202386_NOI Application_20200623

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/8/2020 3:30:32 PM (NCG01 NOI Submission)
Approve by Clark, Paul 6/8/2020 4:30:59 PM (Review- Construction NOI 26691)
. The task was assigned to Clark, Paul by round robin distribution 6/8/2020 3:30 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 10, 2020 5:00 PM
6/8/2020 3:30 PM
Submit by EADS\smccoy2 6/23/2020 10:50:06 AM (Payment Verification for NCC202386)
* Southeastern Regional Medical Center
• EADS\smccoy2 assigned the task to EADS\smccoy2 6/23/2020 10:49 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: July 20, 2020 5:00 PM
6/8/2020 4:31 PM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * 2020 BUILDING ADDITION AT GIBSON CANCER CENTER
1 b. Specific Lot This field nay be used to list specifc lot nunbers.
Numbers
2. County* Robeson
3. Highway or Street PINE RUN DRIVE
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* LUMBERTON
5. State * NC
6. Zip Code * 28358
7. Latitude* Enter the latitude in decirral degrees
34.6586
8. Longitude* Enter the longitude in decir al degrees (M.JST be negative)
-78.9924
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*
06/15/2020
Estimated Construction Project Start Date
10. Date to End*
12/31/2020
Estimated Construction Project End Date
11. SIC (Primary) *
Other (9999)
Standard Industrial aassification for Leveloprrent
12. Acres to be
4.00
disturbed*
(including off -site borrow and waste areas)
13. Total site area 11.47
(acres) *

14. Post- 8.66
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-ROBES-2020-2020 BUILDING ADDITION AT GIBSON
Tracking ID CANCER CENTER
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 Ivey Branch
Wate rbody* %rre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 14-12-6-1
Index No.* NCWaterbody Index Nunber
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. ^
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 Legally Pesponsible Entity
Name * SOUTHEASTERN REGIONAL MEDICAL CENTER
IF pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name * Jason
IF Corporation, enter Faegistered Agent First Wre
3. Last Name* Cox
IF Corporation, enter F;bgistered Agent Last %ne
3b. Title Chief Operating Officer
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-671-5675
Telephone No.*
6. Permittee Mailing Street Address
Address* 300 West 27th Street
Address Line 2
PO BOX 1408
City
Lumberton
Fbstal / Zip Code
28358-3075
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
300 W 27TH STREET
Address Line 2
city
LUMBERTON
Fbstal / Zip Code
28358
8. Type of Individual
Ownership *
State / Frovince / Fbgion
NC
Country
US
State / Ftovince / Region
NC
Country
US

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
..................................................................................................................................................................................................................
1. Primary Site
LARRY
Contact - First
Name *
2. Primary Site
ANDERSON
Contact - Last
Name*
3. Title
PE
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-671-9530
Telephone No.*
6. Organization
ANDERSON ENGINEERING & ASSOC., P.A.
Name
7. Site Contact
Street Address
Mailing Address*
305 North Chippewa Street
Address Line 2
City
State / Rovince / Region
Lumberton
NC
Fbstal / Zip Code
Country
28358-5821
us
8. Consultant Name
(Optional)
BRAD FARLOW
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
984-222-0572
Telephone No.

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 06/03/2020
Approved *
2. E&SC Plan Project ROBES-2020-024
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 or
include the beginning point and end point coordinates in the "Notes" box below.
5. E&SC Plan robes-2020-024.pdf
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.
80.31 KB
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 NCG01 Notice of Intent Certification Form
Form 33.36KB
6_8_20. pdf
Mast be FCFfon-rat
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
r 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 * Jason Cox
Title Chief Operating Officer
Organization Legally Plesponsible Entity
Southeastern Regional Medical Center
Date * 06/08/2020

F. Tracking and COC Info
NOI Tracking No. 26691
NC Reference No. NCG01-2020-2386
Uses 'count number' variable (incremrented by SP)
Certificate of NCC202386
Coverage (COC) Uses 'count number' variable (incremented by SP)
No.*
Count Number 2386
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.)