NCC214580_NOI Application_20210812

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 8/10/2021 4:12:20 PM(NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 8/11/2021 8:16:05 AM(Review-Construction NOI 61868)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 8/10/2021 4:12 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:August 12,2021 5:00
PM 8/10/2021 4:12 PM
Submit by Selkane,Aziza 8/12/2021 9:06:46 AM(Payment Verification for NCC214580)
* William K. Malpass
• Selkane,Aziza assigned the task to Selkane,Aziza 8/12/2021 9:05 AM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is: September 22,2021 5:00
PM 8/11/2021 8:16 AM

�ThF1
1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Eliminatio em 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIMATER DISCHARGES associated with construction activities(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting f•No
an NOI that was r Yes
rejected before?
1a. Project Name* North Creek Commercial Park Lot 6
1 b.Specific Lot This field rray be used to list specifc lot numbers.
Numbers North Creek Commercial Park Lot 6
1 c. Parcel ID List all Rios associated w ith this project.
Number(s)(PIN) 86926
2. County* Pitt
3. Highway or Street North Creek Drive
Address* Street name only is acceptable if no address number assigned yet
4.City or Township* Pactolus
5. State* NC
6.Zip Code* NC
7. Latitude* Enter the latitude in decirral degrees
35.6429
8. Longitude* Enter the longitude in decimal degrees(MJSTbe negative)
-77.3343
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* 09/01/2021
Estimated Construction Project Start Rate
10. Date to End* 06/01/2022
Estimated Construction Project End Date
11.SIC(Primary)* Commercial(1542)
Standard Industrial aassification for Development
12.Acres to be 2.30
disturbed* (including off-site borrow and waste areas)

13.Total site area 3.06
(acres)*
14. Post- 1.25
construction (Estimated)
impervious area
(acres)*
Project Tracking ID NCC-PITT-2021-North Creek Commercial Park Lot 6
Assigned automatically(not used)
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 Cannon Swamp
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b.Waterbody 28.99-1-1
Index No.* NCWaterbody Index Number
Stormwater V 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. ^
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* Fortner Commercial 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* Tyler
If Corporation,enter Faegistered Agent First Wre
3. Last Name* Fortner
It Corporation,enter Pbegistered Agent Last%rre
3b.Title Managing Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* 3910 US Highway 264 East
Address Line 2
City State/Frovince/Fbgion
Greenville NC
Fbstal/Zip Code Country
27834 usa
Check box if the V Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 3910 US Highway 264 East
Address Line 2
City State/Frovince/Faegion
Greenville NC
Fbstal/Zip Code Country
27834 usa
8.Type of ONnership is only individual if an individual is naned in B.1.above.
Ownership* Non-Government

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1. Primary Site Tyler
Contact-First
Name*
2. Primary Site Fortner
Contact-Last
Name*
3.Title Managing Member
4.Site Contact E- [e-mail]
mail Address*
5.Site Contact [phone]
Telephone No.*
6.Organization Fortner Commercial LLC
Name
7.Site Contact Street Address
Mailing Address* 3910 US Highway 264 East
Address Line 2
city State/Rovince/Region
Greenville NC
Postal/Zip Code Country
27834 usa
8. Consultant Name (Optional)
Malpass&Associates
First and Last nacre
9. Consultant E-mail [e-mail]
This person will be copied on all correspondence.
10. Consultant 2527561780
Telephone No.
11. Billing E-mail (For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-rrail
12. Billing (For Annual Fee correspondence)
Telephone [phone]
Default is legally responsible person telephone

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 08/09/2021
Approved*
2. E&SC Plan Project ESCP-2021-0034
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. Please also upload a site map showing 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 ESCP-2021-0034 North Creek Commercial Park Lot
Approval letter or 167.45KB
6 Letter of Approval.pdf
Grading Permit
Mast be FDFforrrat
6.Site Location Map Mast be RDFfornat(linit 201VB)
p 1279con-VICINITYMAP.pdf 56.54KB
Rease do not upload entire set of E&SC plans.
7. Notes(Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application.Include additional waterbodies if necessary.
8. NOI Certification NCG01-ENOI-CERTIFICATION-FORM-
Form 551.13KB
NORTHCREEKLOT6SIGNED-8.10.2021.pdf
Mast be FCFforrrat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66(1) provides that:
Anyperson who knowinglymakes any false statement,representation,or certification in anyapplication,record,report,plan,or other
documentfiled 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 underthis 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 guiltyofa Class 2 misdemeanor which mayinclude 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 Legally Responsible Person named on this Notice of Intent
f 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 NCG010000 General Permit. For more
information on signatory requirements,see Part IV,Section B, Item(6)of that permit.
Signature
%&t 'tr"rt
Type Name* Tyler Fortner
Title Managing Member
Organization Legally Iesponsible Entity
Fortner Commercial LLC
Date* 08/10/2021

F. Tracking and COC Info
NOI Tracking No. 61868
NC Reference No. NCG01-2021-4580
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC214580
Coverage (COC) Uses'count_nurrber'variable(increrrented by SP)
No.*
Count Number 4580
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed(used to assign YY digits after"NOC'in COCno.)
Initial Invoice No. NCC214580-2021
Invoice Due Date 9/10/2021
Initial Fee $ 100.00
Invoice Status OPEN