NCC202373_NOT Signed Certification_20220706

N0001 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61` Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, pion, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... 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 (check all boxes to indicate your agreement):
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.
L' The information submitted in this N01 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.
1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
Jc 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.
Name of Project: `%A►v N YOP K GiZoo
Legally Responsible Organizational Entity: A LrT-o //�ALL ?iLa tzf T`9 LLC.
Legally Responsible Person: Cq(?—E6 in ?_ \J �. log tL
Title of Legally Responsible Person: /qq„I A (,('(L
*Signature: Date:
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: 53C - � 41- � 2_00
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that 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 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coeerage under North Carolina's
{ r General Pennit NCG010000: STORMJVATER DISCHARGES associated with construction actiuties (or
NCG250000)
A. Project Information
Part A.
Loc e& n and V1E abody tfanrOkn
Are you submitting 0 No
an NOI that was f• Yes
rejected before?
Previous Rejected 23903
NOI No. Fiter the N01 no. (rejections aftm4tVM will prel opdate forMw hen you mNe to the next fi"
By which reviewer? We can alert the previous reviewer abut ft re-sbxnittal
Jim Farkas
1a. Project Name * Vann York Group
1 b. Specific Lot This field Trey be used to 19 speafc tit nunbers.
Numbers
2. County* Guilford
3. Highway or Street 422 Eastchester Drive
Address * Street name arty is acceptede if no address m rber assOvd ,;
4. City or Township* Iigh Point
5. State* NC
6. Zip Code * 27262
7. Latitude * 6rter the Mokle in dec:iirrel degrees
35.9837
8. Longitude * Enter the longihide in dearrel degrees (MJSrbe negative)
-80.0117
V you do not know the latitude and longitude coordinates for this project, y::,. can search the location on this map of
North Carolina. Look for the coordinates in the bottom left corner.
9. Date to Begin* 04/01/2020
Estirreied Oinstruction Rnject Start Lie
10. Date to End* 12/31/2020
Estirreted Qinsiniction RnjeCt End Date
11. SIC (Primary) * Commercial (1542)
Standard Industrial Classification for Develop mt
A

12. Acres to be 4.00
disturbed* (hduckVoff-sitebormandwasteareas)
13. Total site area 10.60
(acres) *
14. Post- 7.10
construction (t"tmod)
impervious area
(acres) *
Project Tracking ID NCC-GUILF-2020-Vann York Group
Assigned a#araticaly
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 ►asters downstream of those unless the project extends there. You
may enter up to 3 waterbodies if needed.
15a. Receiving West Fork Deep River (Oak Hollow
Waterbody* Reservior)
Narre of waterbody M which stamNater ruff w ildschargs
15b. Waterbody 17-3-(0.7)
Index No.* MMerbody Wax Nirber
Ensure the right box is checked and review previous waterbody entries.
Stormwater W No
discharges will flow r Yes
to additional
waters *
16a. Is this project r Yes
subject to the NC C No, not subject to NC SPCA
Sediment Pollution
Control Act?*
Note: Stormwater discharges from construction activities associated VAth oil and gas exploration, production,
processing, treatment, or transmission facilities are eligible for thee mption from NPDES permit coverage except
in very limited instances. Do not proceed with this application before cons ting this EPA fact sheet and verifying a
permit applies.

B. Permittee Information
Part B.
RL,rrnttee hntonrntion. - Legally Respc rs,ble Erltity and Individual
Important: The person who signs the NOI Certification Form and signs the Certification in Section Eof 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 Responsible &t0ty
Name * Auto Mall Property, LLC
If rerrnree is an individual (i.e.; orgar,zaton does not art1y). enter *ins: and last na e ;n the field.
2. First Name * Gregory
If Ccyporatiai. enter Registered Agent Frs ,%r*p
3. Last Name * York
f Corporatoi, enter Registered Agent Last W e
Enter Permittee Title. This information is not captured from a previously rejected eNO1 form.
3b. Title * Manager
4. Permitee E-mail gyork@vannyorkauto,com
Address *
5. Permittee 336-841-6200
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box5668
Address L ne 2
oty
High Point
Pastal i Zip Cale
27262
Check box if the r- Yes
street address the
same as mailing
address
State/ Pnvince % Regiw'
NC
C,A)untry
US
7. Permittee Street
street Address
Address*
422 Eastchester Drive
Address Une 2
Q,y
State; Rovince Region
High Point
NC
Rzstal i Zip Code
Country
27262-7631
us
8. Type of
Non -Government
Ownership

C. Site Contact information
Part C.
Reject Site Caitact In`orrnt:on
1. Primary Site Steve
Contact - First
Name*
2. Primary Site Denny
Contact - Last
Name *
3. Title CONSTRUCTION MANAGER
4. Site Contact E- [e-mail]
mail Address * Th.s r.)erson will be copied or, all corresrxx,delce.
5. Site Contact 336-454-6131
Telephone No.
6. Organization Kirkland Builders
Name
7. Site Contact Street Address
Mailing Address* 4140 Mendenhall Oaks Parkway
Address Line 2
Gty
State % Rovirce Pe - goo
High Point
NC
Fibstal I Zip Cude
C entry
27265
US
If applicable, enter consultant contact details below. This information is not captured from a previously
rejected eNO1 form.
8. Consultant Name
(Crtional)
Rich Glover
First and Last narre
9. Consultant E-mail
[e-mail]
-This person will be c-pied on all correspondence.
10. Consultant
336-886-5523
Telephone No.

D. E&SC Plan
Part D.
Erosion & Sed na t Cored (B&SC) Nan Approval ttorrmaw
1. Date E&SC Plan 03/26/2020
Approved *
2. E&SC Plan Project EN-20-0021
Nurrtber/ID * Assggvd by agency or local program
Ensure the right approved by option is chosen and review prev ioyis entries.
3. E&SC Plan
Approved by*
4. Local Program*
C, State DEQ Office
:' Local Program
City of sigh Point
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 LOA.pdf 1.83MB
Approval letter or MW WR7Fzomd
Grading Permit*
6. Site Location Map I%Iprtlfor6ieerprojearevieWv.
(Optional) Mst be R F forret. Reese do not upload entire set of E&SC plaps.
7. Notes (Optional) Pmvide any a ddlional'utarmatim that nigk t help the r&Aeaver baler uximstand how uploaded does sLpport
the applicabm hdude addbonat waterbodes for wear projects if necessary.
B. NOI Certification Honda-NOI•CerLpdf 75.39KB
Form * Mst be R F fomit
A
YOU MUST MAIL THE ORIGINAL SIGNED NOI CERTIFICATION FORM (click on this link) to The Storff ester Program
at the address on the form for the application to fulfill federal application requirements. The Certification Form must be
signed by the person listed in Section B (Permittee Information) or by an aythoriaed responsible person within the same
organize tion. NOTE: The person who signs the paper form must be the same person to electronically certify
and sign the eNOI.
This is an Express r No
Review Project* r' Yes

E. Certification
North Carolina General Statute 143-215.6B (1) provides that:
Anyperson who knowinglymakes 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 Article; or who knowingly makes a false statement
of a material fad in a rulemaking proceeding or contested case underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate anyrecor rding or monitoring deuce or method required to be operated or maintained underthis Artide or rules of the
Commission implementing this Adde shall be guiltyof a Class 2 misdemeanor which mayindude a fine not to exceed ten thousand
dollars ($10,000).
Under penalty of law, I certify that:
* R 1 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.
* R The information submitted in this NOI is, to the best of rry knowledge and belief,
true, accurate, and complete based on rrry inquiry of the person or persons who
manage the system, or those persons directly responsible for gathering the
information.
* p I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* R if the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part 11(Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit, I will nonetheless ensure that all conditions of Part
li of the permit are met on the project at all times.
* R 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
C 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, Rem (6) of the NCG010000 General Permit. For more
information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature *
y rrM4
Type Name'Gregory V. York
Title * Manager
Organization * LAN Paspombe Bitity
Auto Mall Property, LLC
Date * 04/16/2020