NCC203862_NOI Application_20200903

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/2/2020 11:48:49 AM (NCG01 NOI Submission)
Approve by Gwinn, Matt 9/2/2020 2:53:43 PM (Review- Construction NOI 30850)
• Morman, Alaina reassigned the task to Gwinn, Matt 9/2/2020 1:12 PM
• The task was assigned to Morman, Alaina by round robin distribution 9/2/2020 11:49 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 4, 2020 5:00
PM 9/2/2020 11:49 AM
Submit by Selkane, Aziza 9/3/2020 8:18:21 AM (Payment Verification for NCC203862)
* Mike Hill
• Selkane, Aziza assigned the task to Selkane, Aziza 9/3/2020 8:17 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 14, 2020 5:00 PM
9/2/2020 2:53 PM

.• SThF� ';
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 30848
NOI No.
Prior Reviewer Matt Gwinn
Name
1a. Project Name * Sam's Xpress Car Wash - Clayton, NC
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
2. County* Johnston
3. Highway or Street 12856 US Hwy 70 Bus
Address * Street narre only is acceptable if no address number assigned yet
4. City or Township* Clayton
5. State * NC
6. Zip Code * 27520
7. Latitude * Enter the latitude in decimal degrees
35.6657
8. Longitude* Enter the longitude in decimal degrees (MJSTbe negative)
-78.4961
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* 12/07/2020
Estimated Construction Project Start Date
10. Date to End* 06/11/2021
Estimated Construction Project End Cute
11. SIC (Primary)* Commercial (1542)
Standard Industrial Classification for Developrrent

12. Acres to be 2.91
disturbed* (including off -site borrow and waste areas)
13. Total site area 3.75
(acres) *
14. Post- 1.83
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-JOHNS-2020-Sam's Xpress Car Wash - Clayton, NC
Tracking ID 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 Little Creek
Wate rbody* %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 27-43-12
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 Pesponsible Entity
Name * SXCW Properties II, LLC
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Sami
IF Corporation, enter Faegistered Agent First %rre
3. Last Name* Nafisi
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Member / Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 910-986-8849
Telephone No.*
6. Permittee Mailing Street Address
Address* 7935 Council Place
Address Line 2
City State / Frovince / Fbgion
Matthews NC
Fbstal / Zip Code Country
28105-5000 us
Check box if the F Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
7935 Council Place
Address Line 2
City
State / Frovince / Region
Matthews
NC
Fbstal / Zip Code
Country
28105-5000
us
8. Type of
Non -Government
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Chris
Contact - First
Name *
2. Primary Site
Morgan
Contact - Last
Name *
3. Title
Development Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
910-986-8849
Telephone No.
6. Organization
Sams Xpress Car Wash
Name
7. Site Contact
Street Address
Mailing Address*
7935 Council Place
Address Line 2
city
Matthews
Fbstal / Zip Code
28105-5000
8. Consultant Name
(Optional)
First and Last narre
9. Consultant E-mail
This person will be copied on all correspondence.
10. Consultant
Telephone No.
State / Rovince / Region
NC
Country
us

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 06/18/2020
Approved *
2. E&SC Plan Project JC-20-037-C
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Johnston County
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 20-037 Sams Xpress ESC appr 6.18.2020 revised
Approval letter or 210.89KB
9.2.2020.pdf
Grading Permit
Mist be FDFfon-rat
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.
Please see attached resolution
8. NOI Certification NOI Certification Form.pdf 656.31KB
Form Authority signatures.pdf 1.31 MB
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
IT 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
G1f1 !S 410"
Type Name* Chris Morgan
Title Development Manager
Organization Legally Ibsponsible Entity
SXCW Properties II, LLC
Date * 09/02/2020

F. Tracking and COC Info
NOI Tracking No. 30850
NC Reference No.
NCG01-2020-3862
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC203862
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 3862
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. NCC203862-2020
Invoice Due Date 10/2/2020
Initial Fee $ 100.00
Invoice Status OPEN