NCC204081_NOI Application_20200924

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/15/2020 4:57:52 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 9/17/2020 2:16:55 PM (Review- Construction NOI 31481)
• The task was assigned to Garcia, Lauren V by round robin distribution 9/15/2020 4:58 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 17, 2020 5:00
PM 9/15/2020 4:58 PM
Submit by Selkane, Aziza 9/24/2020 1:35:55 PM (Payment Verification for NCC204081)
* County Of Vance
• Selkane, Aziza assigned the task to Selkane, Aziza 9/24/2020 1:35 PM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 29, 2020 5:00 PM
9/17/2020 2:17 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 * Vance County Convenience Site
1 b. Specific Lot This field any be used to list specifc lot numbers.
Numbers N/A
2. County* Vance
3. Highway or Street 871 Warrenton Road
Address* Street narre only is acceptable if no address number assigned yet
4. City or Township* Henderson
5. State * NC
6. Zip Code * 27537
7. Latitude* Enter the latitude in decimal degrees
36.3496
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-78.3651
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*
09/16/2020
Estinated Construction Project Start Date
10. Date to End*
12/31/2020
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
2.60
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.00
(acres) *

14. Post- 0.55
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-VANCE-2020-Vance County Convenience Site
Tracking ID Assignedautorraticaly
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 Anderson Swamp Creek
Waterbody * %rre of waterbody into which stornwater runoff will discharge
15b. Waterbody 23-8-6-(1)
Index No.* NCWaterbody Index Nunber
Stormwater r No
discharges will flow pr Yes
to additional
wate rs *
15c. Additional Sandy Creek
Receiving Waterbody narre
Waterbody
15d. Waterbody 28-78-1-(1)
Index No. NCWaterbody Index Narrber
15e. Additional Waterbody narre
Receiving
Waterbody
15f. Waterbody NCWaterbody Index N nber
Index No.
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 * Vance County
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 * Jordan
If Corporation, enter Faegistered Agent First %rre
3. Last Name* McMillen
It Corporation, enter Pbegistered Agent Last %rre
3b. Title County Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 2527382002
Telephone No.*
6. Permittee Mailing Street Address
Address* 122 Young Street
Address Line 2
Suite B
City
Henderson
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
Fbstal / Zip Code
27536
V Yes
Street Address
122 Young Street
Address Line 2
Suite B
city
Henderson
Fbstal / Zip Code
27536
State / Frovince / Fbgion
NC
Country
us
State / Ftovince / Faegion
NC
Country
us
8. Type of Government - County
Ownership*

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Jason
Contact - First
Name *
2. Primary Site
Falls
Contact - Last
Name *
3. Title
Environmental Services Director
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9196910928
Telephone No.
6. Organization
Vance County
Name
7. Site Contact
Street Address
Mailing Address*
122 Young Street
Address Line 2
Suite B
city
Henderson
Fbstal / Zip Code
27536
8. Consultant Name
(Optional)
Preston Royster
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
9196820368
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 08/14/2019
Approved *
2. E&SC Plan Project VANCE-2020-002
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 * Raleigh (RRO)
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 VANCE-2020-002 LOA 20190814.pdf 59.4KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Helpful for linear project review
(Optional) NC_Vicksboro_20160627_TM geo- cropped to site
811.77KB
1857 - 8.5x11.pdf
Mast be R7F format. Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Frovide any additional information that might help the reviewer better understand how uploaded documents support
the application. Include additional w aterbodies for linear projects if necessary.
8. NOI Certification NCG01-eNO1-Certification-Form-20190919-DEMLR-
Form 42.28KB
SW - signed.pdf
Wst be RDFformat
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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Atide or rules of the
Commission implementing this Atcle 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 * Jordan McMillen
Title County Manager
Organization Legally Responsible Entity
Vance County
Date * 09/15/2020

F. Tracking and COC Info
NOI Tracking No. 31481
NC Reference No. NCG01-2020-4081
Uses 'count_nunber' variable (increrrented by SP)
Certificate of NCC204081
Coverage (COC) Uses 'count nurrber' variable (increrrented by SP)
No.*
Count Number 4081
Sequential nunber for subnittal 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. NCC204081-2020
Invoice Due Date 10/17/2020
Initial Fee $ 100.00
Invoice Status OPEN