NCC192068_NOI Application_20190927

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 9/26/2019 9:01:52 AM(NCG01 NOI Submission)
Approve by Clark, Paul 9/26/2019 11:09:24 AM(Review-Construction NOI 16325)
• The task was assigned to Clark, Paul by round robin distribution 9/26/2019 9:02 AM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is: September 30,2019 5:00
PM 9/26/2019 9:02 AM
Submit by McCoy,Suzanne 9/27/2019 12:42:37 PM(Payment Verification for NCC192068)
* Crossroads Rescue Mission
• McCoy, Suzanne assigned the task to McCoy,Suzanne 9/27/2019 12:42 PM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is: November 7,2019 5:00
PM 9/26/2019 11:09 AM

E, • 1 • • 1 III • 1
1 sees �' � ••. -• i •• i i• i
IY sell
NORTH CAROLINA
Environmental QUII
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Crossroads Rescue Mission
2. County* Cleveland
3. Highway or Street Dekalb St.
Address* Street narra only is acceptable if no address nurrber assigned yet
4. City or Township* Shelby
5. State* NC
6.Zip Code* 28152
7. Latitude* Enter the latitude in decirral degrees
35.2594
8. Longitude* Enter the longitude in decirral degrees(MUST be negative)
-81.5591
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* 01/30/2020
Estimated Construction Project Start Date
10. Date to End* 01/30/2021
Estimated Construction Project End Date
11. SIC(Primary)* Commercial(1542)
Standard Industrial gassification for Developrmnt
12.Acres to be 3.75
disturbed* (including off-site borrow and waste areas)
13.Total site area 5.03
(acres)*
14. Post- 1.74
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-CLEVE-2020-Crossroads Rescue Mission
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. 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 First Broad River
Waterbody* fbrre of waterbody into which storrrwater runoff will discharge
15b.Waterbody 9-50-(28)
Index No.* NCWaterbody Index Narrber
Stormwater rJ 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
.....................................................................................................................................................................
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 Crossroads Rescue Mission
Name*
2. First Name* Rocky
ff Corporation,enter Registered Agent First l\b e
3. Last Name* Shelton
ff Corporation,enter Registered Agent Last Barre
3b.Title Executive Director
4. Permitee E-mail [e-mail]
Address*
5. Permittee [phone]
Telephone No.*
6. Permittee Mailing Street Address
Address* P.O. Box2090
Address Line 2
City State/Province/Region
Shelby NC
Postal/Zip Code Country
28151 USA
Check box if the r Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 206 Mount Sinai Church Rd.
Address Line 2
City State/Province/Region
Shelby NC
Pastal/Zip Code Country
28152 USA

C. Site Contact Information
Part C.
Project Site Contact Information
....................................................................................................................
1.Type of Non-Government
Ownership*
2. Primary Site Rocky
Contact-First
Name*
3.Primary Site Shelton
Contact-Last
Name*
4.Title Executive Director
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact [phone]
Telephone No.*
7.Organization Crossroads Rescue Mission
Name
8.Site Contact Street Address
Mailing Address* P.O. Box2090
Address Line 2
City State/Province/Region
Shelby NC
Fbstal/Zip Code Country
28151 USA
9.Consultant Name (optional)
Larissa Coles
First and Last name
10.Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant [phone]
Telephone No.

D. E&SC Plan
Part D.
Erosion&Sediment Control(E&SC)Ran Approval Information
....................................................................................................................................................................................................................................... .............................................................................................
1. Date E&SC Plan 04/03/2019
Approved*
2. E&SC Plan Project CLEVE-2019-007
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* Mooresville(MRO)
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 jm3-04032019.pdf 844.31 KB
Approval Mist be FDFforrrat
letter/documentation
6. NOI Certification NOI Form.pdf 498.23KB
Form Mist be R7Fforrrat
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 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* Rocky Shelton
Title Executive Director
Organization Crossroads Rescue Mission
Date* 09/26/2019

F. Tracking and COC Info
NOI Tracking No. 16325
NC Reference No. NCG01-2019-2068
Uses'count number variable(incremented by SP)
Certificate of NCC192068
Coverage (COC) Uses'count_nunber'variable(increrrented bySP)
No.*
Count Number 2068
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.)