NCC191473_NOI Application_20190821

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/19/2019 11:50:37 AM (NCG01 NOI Submission)
Approve by Lucas, Annette 8/19/2019 5:16:51 PM (Review- Construction NOI 14999)
• The task was assigned to Lucas, Annette by round robin distribution 8/19/2019 11:50 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: August 21, 2019 5:00
PM 8/19/2019 11:50 AM
Submit by McCoy, Suzanne 8/21/2019 10:25:20 AM (Payment Verification for NCC191473)
* D. Todd Brown.
• McCoy, Suzanne assigned the task to McCoy, Suzanne 8/21/2019 10:24 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: September 2, 2019 5:00
PM 8/19/2019 5:17 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * East Coast Oxygen and Hydro
2. County* Randolph
3. Highway or Street Turnpike Ct
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Trinity
5. State * NC
1r-i)iTII1T7G)MF11i(-_TiIa1010
6. Zip Code* 27360
7. Latitude * Enter the latitude in decirral degrees
35.8850
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-80.0446
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* 09/09/2019
Estimated Construction Project Start Date
10. Date to End* 01 /30/2020
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 1.40
disturbed* (including off -site borrow and waste areas)
13. Total site area
1.79
(acres)*
14. Post-
1.00
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-RANDO-2019-East Coast Oxygen and Hydro
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 North Hamby Creek
Wate rbody* Nacre of waterbody into which stormuater runoff will discharge
15b. Waterbody 12-119-7-4-1
Index No. * NCWaterbody Index Narrber
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 East Coast Oxygen & Hydro Testing, Inc.
Name *
2. First Name* Todd
ff Corporation, enter Registered Agent First l\b e
3. Last Name * Brown
Y Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 3368705454
Telephone No.*
6. Permittee Mailing Street Address
Address* PO Box 1349
Address Line 2
City
Thomasville
Postal / Zip Code
27360
Check box if the r Yes
street address the
same as mailing
address
State / Province / Region
NC
Country
United States
7. Permittee Street Street Address
Address* 320 Habersham Road, Unit 103
Address Line 2
City State / Province / Region
High Point NC
Rastal / Zip Code Country
27260 United States

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Todd
Contact - First
Name *
3. Primary Site Brown
Contact - Last
Name *
4. Title President
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 336-870-5454
Telephone No.*
7. Organization East Coast Oxygen & Hydro Testing Inc.
Name
8. Site Contact Street Address
Mailing Address* PO.Box 1846
Address Line 2
city
Thomasville
Rbstal / Zip Code
27361
State / Province / Region
NC
Country
USA

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 08/09/2019
Approved *
2. E&SC Plan Project RANDO-2020-001
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 RANDO-2020-001_8-9-19.pdf 318.44KB
Approval Mist be RDFfornat
letter/documentation
6. NOI Certification CCF08142019_0012.pdf 784.07KB
at
Form Mist be RDFforn
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 * Todd Brown
Title President
Organization East Coast Oxygen & Hydro Testing Inc.
Date * 08/19/2019

F. Tracking and COC Info
NOI Tracking No. 14999
NC Reference No. NCG01-2019-1473
Uses 'count number variable (incremrented by SP)
Certificate of NCC191473
Coverage (COC) Uses'count_nunber'variable (incremrented by SF)
No. *
Count Number 1473
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.)