NCC213230_NOI Application_20210601

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/26/2021 9:29:04 AM (NCGO1 NOI Submission)
App— by EADS\bcbroussard 5/27/2021 12:00:29 PM (Review - Construction NOI 53605)
* Morman, Alaina reassigned the task to EADS\bcbroussard 5/27/2021 11:22 AM
• The task was assigned to Clark, Paul B by round robin distribution 5/26/2021 9:30 AM
• The task was assigned to DEMLR NCGO1 NOI Review Team. The due date is: May 28, 2021 5:00 PM.
The priority is: High 5/26/2021 9:30 AM
Submit by Selkane, Aziza 6/1/2021 1:34:46 PM (Payment Verification for NCC213230)
Second Harvest Food Bank of Northvvest NC, Inc
Selkane, Azjza assigned the task to Selkane, Azjza 6/1/2021 1:33 PM
The task was assigned to DEMLR NCGO1 Payment Team. The due date is: July 8, 2021 5:00 PM. The
priority is: High 5/27/2021 12:00 PM

NORTH CAROLINA
ErpirironmertW quailly
A. Project Information
Part A.
Project Location and Waterbody Inforrnation
Are you submitting
IT No
an N01 that was
r Yes
rejected before?
1 a. Project Name
Second Harvest Food Bank
1b. Specific Lot
This field nray be used to list specffc lot nunbers.
Numbers
Whitaker Park East Lots 1 & 2
1c. Parcel ID List all R% associated w ith this project.
Number(s) (PIN) 6837-00-3923
2. County * Forsyth
3. Highway or Street 3330 Shorefair Drive
Address* Street narre only is acceptable if no address nunber assigned yet
4. Cityor Township* Winston-Salem
5. State * NC
6. Zip Cocle* 27105
7. Latitude* Enter the latitude in decirral degrees
36.1365
8. Longitude Enter the longitude in clecirral degrees (MJST be negative)
-80.2521
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*
06/15/2021
Estirrated 0:)nstruction Project Start Date
10. Date to End
12/31/2021
Estirrated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial aassif ication for Developnent
12. Acres to be
12.74
disturbed*
(including off -site borrow and waste areas)

13. Total site area 14.43
(acres)*
14. Post- 6.44
construction (Estin-eted)
impervious area
(acres) *
NCC Project NCC-FORSY-2021 -Second Harvest Food Bank
Tracking ID Assigned autorratically
Below you must enter waterbody information for surface waters affected by this project. Pleaseconsult
IDWR'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 Monarcas Creek
Waterbody* �bn-e of w aterbody into w hich storrrw ater runoff w ill discharge
15b. Waterbody 12-94-7-5
Index No.* NCWaterbody Index Rinber
Sto rmwate r V No
discharges will flow F— 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.
Flarnittee Inforrration - Legally Fbsponsible Entity and Individual
..................................... ­­ ................................................................ ­­­­­­­ ....................................................................................................... ...................
Important: The person vVno 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 ovvns 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 NCGO1 0000 General Permit. For more information on signatory requirements, see Part
IV, Section 13, Item (6) of that permit.
1. Organization Legally Pesponsible Entity
Name Second Harvest Food Bank of Northwest North Carolina, Inc.
If 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 Eric
If Corporation, enter Pbegistered Agent First %rre
3. Last Name* Aft
If Corporation, enter Pbegistered Agent Last %rre
3b. Title CEO
4. Permitee E-mail [e-mail]
Address*
5. Permittee 3367845770
Telephone No.*
6. Permittee Mailing Street Address
Address* 3655 Reed Street
Address Line 2
City
Winston-Salem
Flostal / Zip Code
27107-5428
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
3655 Reed Street
Address Line 2
City
Winston-Salem
Fbstal / Zip Gode
27107-5428
State / Frovince / Pegion
NC
Country
us
State / Frovince / Pbegion
NC
Country
us
8. Type of ON nership is only individual if an individual is nan-ed in B. 1. above.
Ownership Non -Government

C. Site Contact Information
Part C.
Roject Ste Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Eric
Contact - First
Name *
2. Primary Site
Aft
Contact - Last
Name *
3. Title
CEO
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
3367845770
Telephone No.
6. Organization
Second Harvest Food Bank
Name
7. Site Contact
Street Address
Mailing Address
3655 Reed Street
Address Line 2
city
Winston-Salem
Fbstal / Zip Code
27107-5428
8. Consultant Name
(Optional)
Neal Tucker
First and Last nan-e
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
3367231067 x1 104
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-n-ail
12. Billing
(For Annual Fee correspondence)
Telephone
3367845770
Default is legally responsible person telephone
State / Frovince / Pbegion
NC
Country
us

D. E&SC Plan
Part D.
aosion & Sediment Control (E&SC) Ran Approval Information
........................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/25/2021
Approved *
2. E&SC Plan Project EN2100093
Number/ID* Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4. Local Program* Winston-Salem/Forsyth County
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map shoWng the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan CoWS Approval Letter (Email).pdf 140.47KB
Approval letter or Mist be RDF forml
Grading Permit
6. Site Location Map Mist be RDF forn-Bt (linit 20 K/B)
SHFB VIC MAP.pdf 136.95KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Frovide any additional inf ormation that night help the reviewer better understand how uploaded documents support
the application. Include additional waterbodies if necessary.
8. NOI Certification NCGO1 Notice of Intent Certification Form - Second
Form Harvest Food Bank of North\Aest NC.pdf 358.53KB
Mist be FDF format
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613 (1) provides that:
Any person who knoWngly 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 knoWngly 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 of a Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
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.
PF 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.
I will abide by all conditions of the NCGO10000 General Permit and the
approved Erosion and Sediment Control Plan.
PF If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part 11 (Stormwater Pollution Prevention Plan) of the
NCGO1 0000 General Permit. I will nonetheless ensure that all conditions of Part
11 of the permit are met on the project at all times.
I hereby request coverage under the NCGO10000 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 Legally Responsible Person named on this Notice of Intent
r Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
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 NCGO10000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
Type Name* Eric A. Aft
Title Chief Executive Officer
Organization Legally Pesponsible Entity
Second Harvest Food Bank
Date * 05/26/2021

F. Tracking and COC Info
NOI Tracking No. 53605
NC Reference No.
NCGOl-2021-3230
Uses 'count nurrber' variable (increrrented by SP)
Certificate of
NCC213230
Coverage (COC)
Uses 'count—nun-ber' variable (increrrented by SP)
No. *
Count Number 3230
Sequential nurrber for subrrittal that is incren-ented by Stored Frocedure
COC Year 2021
Yearof clatereviewed (used to assign YY digits after "NOMnODCno.)
Initial Invoice No. NCC213230-2021
Invoice Due Date 6/26/2021
Initial Fee $ 100.00
Invoice Status OPEN