NCC205624_NOI Application_20201208

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/7/2020 12:55:32 PM (NCG01 NOI Submission)
Approve by Meloy, Michael 12/7/2020 2:28:59 PM (Review- Construction NOI 38252)
• The task was assigned to Meloy, Michael by round robin distribution 12/7/2020 12:55 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 9, 2020 5:00
PM 12/7/2020 12:55 PM
Submit by Selkane, Aziza 12/8/2020 11:39:51 AM (Payment Verification for NCC205624)
* Kelli Gill
• Selkane, Aziza assigned the task to Selkane, Aziza 12/8/2020 11:39 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: January 18, 2021 5:00 PM
12/7/2020 2:29 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 * Memorial Drive ABC Store
1 b. Specific Lot This field may be used to list specifc lot numbers.
Numbers Pitt Co. Parcel No. 29141
2. County* Pitt
3. Highway or Street 2307 S. Memorial Drive
Address* Street narre only is acceptable if no address number assigned yet
4.CityorTownship* Greenville
5. State * NC
6. Zip Code * 27858
7. Latitude* Enter the latitude in decimal degrees
35.5972
8. Longitude* Enter the longitude in decimal degrees (M.JST be negative)
-77.3947
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*
12/30/2020
Estinated Construction Project Start Date
10. Date to End*
11/30/2021
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Classification for Developrrent
12. Acres to be
1.08
disturbed*
(including off -site borrow and waste areas)
13. Total site area 1.01
(acres) *

14. Post- 1.00
construction (Estirrated)
impervious area
(acres) *
NCC Project NCC-PITT-2020-Memorial Drive ABC Store
Tracking ID Assigned autorraticaly
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 Green Mills Run
Waterbody* Barre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 28-96
Index No.* NCWaterbody Index Number
Stormwater V No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B. ^
Fbrnittee 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 * Pitt County ABC Board
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 * Adam
If Corporation, enter Faegistered Agent First Wre
3. Last Name* Sullivan
It Corporation, enter F;bgistered Agent Last %rre
3b. Title General Manager
4. Permitee E-mail [e-mail]
Address*
5. Permittee 252-756-2350
Telephone No.*
6. Permittee Mailing Street Address
Address* 2082-B Central Park Drive
Address Line 2
City State / Frovince / Fbgion
Winterville NC
Fbstal / Zip Code Country
28590 USA
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street
Street Address
Address*
2082-B Central Park Drive
Address Line 2
City
State / Frovince / Region
Winterville
NC
Fbstal / Zip Code
Country
28590
USA
8. Type of
Government - County
Ownership

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Adam
Contact - First
Name *
2. Primary Site
Sullivan
Contact - Last
Name *
3. Title
General Manager
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
252-756-2350
Telephone No.
6. Organization
Pitt County ABC Board
Name
7. Site Contact
Street Address
Mailing Address*
2082 Central Park Drive
Address Line 2
city
Winterville
Fbstal / Zip Code
28590-7857
8. Consultant Name
(Optional)
Bryan Fagundus
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
252-558-0888
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 11/24/2020
Approved *
2. E&SC Plan Project ESCP-2020-0050
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 Greenville
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 ESCP-2020-0050-Memorial Drive ABC Store.
Approval letter or 214.93KB
Approval.pdf
Grading Permit
Mast be R7Ffon-rat
6. Site Location Map Mist be RDFforrret (lint 201VB)
Exhibit - Quad & Soils-Quad.pdf 1.23MB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Provide 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 2020-12-07 - NOI - Executed.pdf 81.86KB
Form Mist be RDFforrret
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 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 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
Type Name* Adam Sullivan
Title General Manager
Organization Legally Iesponsible Entity
Pitt County ABC Board
Date * 12/07/2020

F. Tracking and COC Info
NOI Tracking No. 38252
NC Reference No.
NCG01-2020-5624
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC205624
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 5624
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. NCC205624-2020
Invoice Due Date 1/6/2021
Initial Fee $ 100.00
Invoice Status OPEN