NCC203734_NOI Application_20200828

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/24/2020 6:20:27 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 8/26/2020 6:14:48 PM (Review- Construction NOI 30358)
• Gwinn, Matt reassigned the task to Garcia, Lauren V 8/25/2020 12:52 PM
• The task was assigned to Gwinn, Matt by round robin distribution 8/24/2020 6:21 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 26, 2020 5:00
PM 8/24/2020 6:21 PM
Submit by Selkane, Aziza 8/28/2020 10:43:09 AM (Payment Verification for NCC203734)
* Gerald A Tanner Jr
• Selkane, Aziza assigned the task to Selkane, Aziza 8/28/2020 10:42 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 7, 2020 5:00 PM
8/26/2020 6:15 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 30209
NOI No.
Prior Reviewer Lauren Garcia
Name
1a. Project Name* 7-Eleven Greensboro
1 b. Specific Lot This field rray be used to list specifc lot numbers.
Numbers
2. County* Guilford
3. Highway or Street 4501 Old Burlington Rd
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Greensboro
5. State * NC
6. Zip Code * 27405
7. Latitude * Enter the latitude in decimal degrees
36.0890
8. Longitude* Enter the longitude in decimal degrees (M. ST be negative)
-79.7000
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* 08/21/2020
Estimated Construction Project Start Date
10. Date to End* 07/09/2021
Estimated Construction Project End Cute
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Developrrent

12. Acres to be 5.02
disturbed* (including off -site borrow and waste areas)
13. Total site area 3.99
(acres) *
14. Post- 2.36
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-G UILF-2020-7- Eleven Greensboro
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 South Buffalo Creek
Wate rbody* %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 16-11-14-2
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. ^
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
Legally Pesponsible Entity
Name *
Convenience Building Group, LLC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
2. First Name *
Sam
IF Corporation, enter Faegistered Agent First %rre
3. Last Name*
Tanner
It Corporation, enter F;bgistered Agent Last %ne
3b. Title
Contractor
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7044413739
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box403
Address Line 2
Cty
Indian Trail
Fbstal / Zip Code
28079
Check box if the F Yes
street address the
same as mailing
address
State / Rovince / Pbegion
NC
Country
USA
7. Permittee Street
Street Address
Address*
PO Box403
Address Line 2
city
State / Frovince / Region
Indian Trail
NC
Fbstal / Zip Code
Country
28079
USA
8. Type of
Non -Government
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
..........................................................................................................................................................................................................
1. Primary Site
Sam
Contact - First
Name *
2. Primary Site
Tanner
Contact - Last
Name *
3. Title
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
7044413739
Telephone No.
6. Organization
Convenience Building Group, LLC
Name
7. Site Contact
Street Address
Mailing Address*
PO Box403
Address Line 2
city
Indian Trail
Fbstal / Zip Code
28079
8. Consultant Name
(Optional)
Dane Fray
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
3212708821
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 06/25/2020
Approved *
2. E&SC Plan Project 2992
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* City of Greensboro
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
Approval Letter (2992).pdf 297.19KB
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
NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form
1.2MB
SW(1).pdf
Mast be FCFfon-rat
This is an Express
r No
Review Project*
r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) 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 If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit. I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* 17 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
6� 9�;;xvi
Type Name* Sam Tanner
Title Contractor
Organization Legally Ibsponsible Entity
Convience Development Partners
Date * 08/24/2020

F. Tracking and COC Info
NOI Tracking No. 30358
NC Reference No.
NCG01-2020-3734
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203734
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3734
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2020
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC203734-2020
Invoice Due Date 9/25/2020
Initial Fee $ 100.00
Invoice Status OPEN