NCC214879_NOI Application_20210927

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/25/2021 11:58:26 AM (NCG01 NOI Submission)
Approve by Broussard, Brooklyn C 8/26/2021 7:18:31 AM (Review- Construction NOI 62946)
• The task was assigned to Broussard, Brooklyn C by round robin distribution 8/25/2021 12:00 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 27, 2021 5:00
PM 8/25/2021 12:00 PM
Submit by Selkane, Aziza 9/27/2021 10:41:36 AM (Payment Verification for NCC214879)
* DSM Investment Properties LLC
• Selkane, Aziza assigned the task to Selkane, Aziza 9/27/2021 10:40 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: October 7, 2021 5:00 PM
8/26/2021 7:19 AM

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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 * Medlin Self -Storage
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
1 c. Parcel ID
List all Rim associated w ith this project.
Number(s) (PIN)
067315 9630
0673 15 9867
2. County*
Harnett
3. Highway or Street 7779 NC-210
Address* Street name only is acceptable if no address nunber assigned yet
4. Cityor Township* Angier
5. State * NC
6. Zip Code* 27501
7. Latitude* Enter the latitude in decimal degrees
35.4962
8. Longitude * Enter the longitude in decinal degrees (MJST be negative)
-78.7571
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*
08/25/2021
Estirrated Construction Project Start Date
10. Date to End *
09/30/2021
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
6.90
d istu rbe d *
(including off -site borrow and waste areas)

13. Total site area 9.59
(acres) *
14. Post- 5.37
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NCC-HARNE-2021-Medlin Self -Storage
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 Hector's Creek
Waterbody* Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 18-15-(0.7)
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.
F2rnittee 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 must 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. Permittee * Legally Pesponsible Entity
DSM Investment Properties, LLC
It pernittee is an individual, enter first and last narre in this field. Otherwise, enter organization/business narre.
Note: If the permittee is a business, the business must be registered with the NC Secretary of State. You can verify the
registration here.
2. First Name * Sheri
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Medlin
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Member
4. Permitee E-mail [e-mail]
Address*
5. Permittee 9192013662
Telephone No.*
6. Permittee Mailing Street Address
Address* 802 Holland Road
Address Line 2
City
Fuquay-Varina
Fbstal / Zip Code
27526
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
802 Holland Road
Address Line 2
City
Fuquay-Varina
Postal / Zip Code
27526
State / Rovince / Pegion
NC
Country
USA
State / Rovince / Faegion
NC
Country
USA
8. Type of Ownership 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
Sheri
Contact - First
Name *
2. Primary Site
Medlin
Contact - Last
Name *
3. Title
Owner
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
9192013662
Telephone No.
6. Organization
DSM Investment Properties
Name
7. Site Contact
Street Address
Mailing Address*
802 Holland Rd
Address Line 2
City
Fuquay-Varina
Postal / Zip Code
27526
8. Consultant Name
(Optional)
Don Curry
First and Last nacre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
9195520849
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
9192013662
Default is legally responsible person telephone
State / Province / Region
NC
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 05/29/2020
Approved *
2. E&SC Plan Project HARNE-2020-133
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 * Fayetteville (FRO)
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 Erosion Control Letter Approval.pdf 245.24KB
Approval letter or Mast beRDFformat
Grading Permit
6. Signed FRO Financial Pesponsibility/Ownership Form
Mast be FDFfornat
7. Site Location Map Mast be RDFforrret (lint 201VB)
ACFrOgCOOE_fstAl1 WHxu5aQ9kGJXOh5U-9-
YBJaEL6KDTuXWfXgRo9sgAO3oLYvPPSknCtUtdM... 161.11 KB
sTC6S 16cSh DBRf5_iQ7sQ84j41 Q-f2Y_nyk=. pdf
Rease do not upload entire set of E&SC plans.
8. Notes (Optional) Frovide any additional information that night help the reviewer better understand how uploaded docurrents support
the application. Include additional waterbodies if necessary.
9. NOI Certification NCG01-eNO1-Certification-Form-20210514-DEMLR-
Form 844.02KB
SW-signed.pdf
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 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:* IT 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
Type Name * Sheri R Medlin
Title Member
Organization Legally Responsible Entity
DSM Investment Properties, LLC
Date * 08/25/2021

F. Tracking and COC Info
NOI Tracking No. 62946
NC Reference No.
NCG01-2021-4879
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC214879
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 4879
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. NCC214879-2021
Invoice Due Date 9/25/2021
Initial Fee $ 100.00
Invoice Status OPEN