NCC192102_NOI Application_20191001

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/27/2019 11:38:52 AM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 9/27/2019 3:52:14 PM (Review- Construction NOI 16392)
• The task was assigned to Garcia, Lauren V by round robin distribution 9/27/2019 11:39 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 1, 2019 5:00
PM 9/27/2019 11:39 AM
Submit by McCoy, Suzanne 10/1/2019 8:21:07 AM (Payment Verification for NCC192102)
* Jason Tarkenton
• McCoy, Suzanne assigned the task to McCoy, Suzanne 10/1/2019 8:20 AM
• The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 8, 2019 5:00
PM 9/27/2019 3:52 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
117-8) &T:M'0) M 1-11 (-:TiI a 1010
1. Project Name * Erosion and Sediment Control Plan & Grading Plan Phase II for the
Front Property
2. County* Guilford
3. Highway or Street 2091 Bishop Road
Address* Street nacre only is acceptable if no address nun-ber assigned yet
4. City or Township * GREENSBORO
5. State * NC
6. Zip Code * 27406
7. Latitude* Enter the latitude in decimal degrees
35.9921
8. Longitude * Enter the longitude in decirral degrees (MJST be negative)
-79.8475
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*
07/01 /2019
Estimated Construction Project Start Date
10. Date to End *
09/01 /2023
Estimated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial Cassification for Developrrent
12. Acres to be
6.56
disturbed*
(including off -site borrow and waste areas)
13. Total site area 6.56
(acres) *
14. Post- 6.56
construction (Estimated)
impervious area
(acres)*

NCC Project NCC-GUILF-2019-Erosion and Sediment Control Plan & Grading
Tracking ID Plan Phase II for the Front Property
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 Hickory Creek
Wate rbody* Nacre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 17-8.5-(1)
Index No. * NC Waterbody Index Ninber
Stormwater PF No
discharges will flow r Yes
to additional
wate rs *
16a. Is this project F Yes
subject to the NC r No, not subject to NC SPCA
Sediment Pollution
Control Act?*

B. Permittee Information
Part B.
Rerrrittee 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 A-1 Sandrock Inc.
Name *
2. First Name* Ronald
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Petty
ff Corporation, enter Registered Agent Last Barre
3b. Title Vice President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 3362076052
Telephone No.*
6. Permittee Mailing Street Address
Address* 2091 Bishop Road
Address Line 2
City
Greensboro
Rastal / Zip Code
27406
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
2091 Bishop Road
Address Line 2
City
Greensboro
Rastal / Zip Code
27406
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Individual
Ownership*
2. Primary Site Jason
Contact - First
Name *
3. Primary Site Tarkenton
Contact - Last
Name *
4. Title General Manager
5. Site Contact E-
[e-mail]
mail Address*
6. Site Contact
3363829707
Telephone No.*
7. Organization
A-1 Sandrock Inc.
Name
8. Site Contact
Street Address
Mailing Address*
2091 Bishop Road
Address Line 2
City
GREENSBORO
Fbstal / Zip Code
27406
9. Consultant Name (Optional)
Jared Hamela
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 7047265814
Telephone No.
State / Rovince / Region
North Carolina
Country
United States

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 06/04/2019
Approved *
2. E&SC Plan Project 19-04-GCCP-02908
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* Guilford County
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 E&SC Plan Approval Guilford County.pdf 173.22KB
Approval Mist be RDFforrrat
letter/documentation
6. NOI Certification NOI.pdf 79.85KB
Form Mist be RJFforrrat
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 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.
* V 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.
* V If the Erosion and Sediment Control Plan approved by the delegated program is
not compliant with Part II (Stormwater Pollution Prevention Plan) of the
NCG010000 General Permit, I will nonetheless ensure that all conditions of Part
II of the permit are met on the project at all times.
* I7 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
;iemalW{��r7? I
Type Name* Ronald Petty
Title Vice President
Organization A-1 Sandrock Inc.
Date * 09/27/2019

F. Tracking and COC Info
NOI Tracking No. 16392
NC Reference No. NCG01-2019-2102
Uses 'count number variable (incremrented by SP)
Certificate of NCC192102
Coverage (COC) Uses 'count _nunber'variable (increrrented bySP)
No. *
Count Number 2102
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.)