NCC190898_NOI Application_20190710

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 7/10/2019 10:51:52 AM(NCG01 NOI Submission)
Approve by McCoy,Suzanne 7/10/2019 1:53:23 PM(Review-Construction NOI 13259)
• The task was assigned to McCoy, Suzanne by round robin distribution 7/10/2019 10:52 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is:July 12,2019 5:00 PM
7/10/2019 10:52 AM
Submit by McCoy,Suzanne 7/10/2019 1:54:16 PM(Payment Verification-NCG01-2019-0898)
• The task was assigned to McCoy, Suzanne.The due date is:July 11,2019 5:00 PM
7/10/2019 1:53 PM

1 sees �' � ••. -• i •• i i• i
IY sell
NORTH CAROLINA
Ernvlronmental QUII
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Hanes MII LF Recycling Area
2. County* Forsyth
3. Highway or Street 325 W Hanes Mill Road
Address* Street narre only is acceptable if no address nurrber assigned yet
4. City or Township* Winston-Salem
5. State* NC
6.Zip Code* 27105
7. Latitude* Enter the latitude in decirral degrees
36.1873
8. Longitude* Enter the longitude in decirral degrees(MJSTbe negative)
-80.2824
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* 07/20/2019
Estimated Construction Project Start Date
10. Date to End* 08/17/2019
Estimated Construction Project End Date
11. SIC(Primary)* Other(0000)
Standard Industrial aassification for Developrrent
12.Acres to be 3.00
disturbed* (including off-site borrow and waste areas)
13.Total site area 24.00
(acres)*
14. Post- 0.00
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-FORSY-2019-Hanes MII LF Recycling Area
Tracking ID Assigned autorratically

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. You may
enter up to 3 waterbodies.
15a. Receiving Grassy Creek
Waterbody* Nacre of waterbody into which stormuater runoff will discharge
15b.Waterbody 12-94-7-3
Index No.* NCWaterbody Index Nanber
Stormwater r No
discharges will flow rj Yes
to additional
wate rs*
15c.Additional Mill Creek
Receiving Waterbody narre
Waterbody
15d.Waterbody 12-94-7
Index No. NCWaterbody Index Ninber
15e.Additional Waterbody nave
Receiving
Waterbody
15f.Waterbody NCWaterbody Index Narrber
Index No.
16a.Is this project r Yes
subject to the NC f No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Perrrittee Information-Legally Responsible 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 The City of Winston-Salem
Name*
2. First Name* Janis
ff Corporation,enter Registered Agent First l\brre
3. Last Name* McHargue
ff Corporation,enter Registered Agent Last Barre
3b.Title Assistant Utilities Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee 336.747.7310
Telephone No.*
6. Permittee Mailing Street Address
Address* 101 North Main Street
Address Line 2
Suite 357
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27101 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 101 North Main Street
Address Line 2
Suite 357
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27101 US

C. Site Contact Information
Part C.
Project Site Contact Information
...............................................................................................
1.Type of Government- Municipal
Ownership*
2. Primary Site Keith
Contact-First
Name*
3.Primary Site Cain
Contact-Last
Name*
4.Title
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 336.399.5056
Telephone No.*
7.Organization The City of Winston-Salem
Name
8.Site Contact Street Address
Mailing Address* 325 West Hanes Mill Road
Address Line 2
Oty State/Province/Fegion
Winston-Salem NC
Fbstal/Zip Code Country
27105-9626 us

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 06/26/2019
Approved*
2. E&SC Plan Project Forsy-2019-044
Number/ID* Assigned by agency or local program
3. E&SC Plan f•State DEQ Office
Approved by r Local Program
4.State DEQ Office* Winston-Salem(WSRO)
Documentation of E&SC Plan approval and the signed Notice of Intent(NOI)Certification Form is required for a
complete application.
5. E&SC Plan Hanes Mill CAB NCDEQ Approval Letter_Sink_06-
Approval 3.78MB
27-2019.pdf
letter/documentation
Mist be R7F format
6. NOI Certification Hanes Mill NOI Certification Form.pdf 296.36KB
Form Mist be RDFfornat
This is an Express f•No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.613(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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case under this Article;or who falsifies,tampers with,or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article 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:
rJ 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.
* I7 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:* r The Responsible Person named on this Notice of Intent
r Authorized Responsible Person*
Important:The person who signs this Certification above and signs the NOI Certification Form should be the same
person(or authorized responsible person within the same organization)as listed in Section B(Permittee Information)
of this form. *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* Janis McHargue
Title Assistant Director of Utilities/Solid Waste
Organization Winston-Salem/Forsyth Co. Utilities
Date* 07/10/2019

F. Tracking and COC Info
NOI Tracking No. 13259
NC Reference No. NCG01-2019-0898
Uses'count number variable(incremented by SP)
Certificate of NCC190898
Coverage (COC) Uses'count_nunber'variable(increrrented bySP)
No.*
Count Number 898
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed(used to assign YY digits after"NGC'in OOCno.)