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HomeMy WebLinkAboutNCC191171_NOI Application_20190731Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 7/31/2019 11:39:33 AM (NCG01 NOI Submission) Approve by Georgoulias, Bethany 7/31/2019 1:29:32 PM (Review- Construction NOI 14291) In Applicant only uploaded first page of E&SC approval letter but e-mailed the reviewer a revised COPY. • The task was assigned to Georgoulias, Bethany by round robin distribution 7/31/2019 11:39 AM • The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 2, 2019 5:00 PM. The priority is: High 7/31/2019 11:39 AM Submit by Georgoulias, Bethany 7/31/2019 1:36:31 PM (Payment Verification - NCC191171: Amenities Center, Phase 1) • The task was assigned to Georgoulias, Bethany. The due date is: August 1, 2019 5:00 PM. The priority is: High 7/31/2019 1:29 PM STME NORTH CAROLINA Ernvlronmentol qualily A. Project Information Part A. Project Location and Waterbody Inforrration 1. Project Name * Amenities Center, Phase 1 2. County* Forsyth 3. Highway or Street Teague Lane Address * Street name only is acceptable if no address nurrtrer assigned yet 4. City or Township* Kernersville 5. State * NC 1r-G)a�T7i)Mfi1if_TiIa10141 6. Zip Code* 27284 7. Latitude * Enter the latitude in decirral degrees 36.0646 8. Longitude * Enter the longitude in decirral degrees (MIST be negative) -80.0905 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 * 08/01 /2019 Estimated Construction Project Start Date 10. Date to End* 12/31 /2020 Estimated Construction Project End Date 11. SIC (Primary)* Commercial (1542) Standard Industrial aassification for Development 12. Acres to be 8.80 disturbed* (including off -site borrow and waste areas) 13. Total site area 9.00 (acres)* 14. Post- 1.00 construction (Estimated) impervious area (acres) * NCC Project NCC-FORSY-2019-Amenities Center, Phase 1 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 Abbotts Creek Wate rbody* Narre of waterbody into which stormuater runoff will discharge 15b. Waterbody 12-119-(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. Perrrittee Information - Legally Responsible Entity and Individual ..................................................................................................................................................................... h 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 BOMA North Carolina, LLC Name * 2. First Name* Debbie ff Corporation, enter Registered Agent First Nacre 3. Last Name * Joyce ff Corporation, enter Registered Agent Last Nbrre 3b. Title Agent 4. Permitee E-mail debbie.joyce@greer-louis.com Address* 5. Permittee 336-669-8189 Telephone No.* 6. Permittee Mailing Street Address Address* 1110-A Dover Road Address Line 2 City Greensboro Postal / Zip Code 27408 Check box if the street address the same as mailing address 7. Permittee Street Address* fJ Yes Street Address 1110-A Dover Road Address Line 2 City Greensboro Rbstal / Zip Code 27408 State / Province / Region NC Country United States State / Province / Region NC Country United States C. Site Contact Information Part C. Roiect Site Contact Information 1. Type of Non -Government Ownership* 2. Primary Site Debbie Contact - First Name * 3. Primary Site Joyce Contact - Last Name * 4. Title Agent 5. Site Contact E- debbie.joyce@greer-louis.com mail Address* 6. Site Contact 336-669-8189 Telephone No.* 7. Organization Name 8. Site Contact Street Address Mailing Address* 1110-A Dover Road Address Line 2 aty Greensboro Fbstal / Zip Code 27408 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 04/29/2019 Approved * 2. E&SC Plan Project Forsy-2019-030 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 D00072519-07252019160330-Modification.pdf 491.33KB Approval Mist be RCFformat letter/documentation 6. NOI Certification Amenity.pdf 75.24KB Form Mist be RJFformat 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 * Debbie Joyce Title Agent Organization BOMA North Carolina, LLC Date * 07/31 /2019 F. Tracking and COC Info NOI Tracking No. 14291 NC Reference No. NCG01-2019-1171 Uses 'count number variable (incremrented by SP) Certificate of NCC191171 Coverage (COC) Uses'count_nunber'variable (incremented by SF) No. * Count Number 1171 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.)