NCC193100_NOI Application_20191210

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 12/4/2019 1:43:23 PM(NCG01 NOI Submission)
Approve by Morman,Alaina 12/6/2019 2:11:19 PM(Review-Construction NOI 19121)
• The task was assigned to Morman,Alaina by round robin distribution 12/4/2019 1:43 PM
• The task was assigned to DEMLR NCG01 NOI Review Team.The due date is: December 6,2019 5:00
PM.The priority is: High 12/4/2019 1:43 PM
Submit by McCoy, Suzanne 12/10/2019 7:41:51 AM(Payment Verification for NCC193100)
* Quanisia Broadie
• McCoy,Suzanne assigned the task to McCoy, Suzanne 12/10/2019 7:41 AM
• The task was assigned to DEMLR NCG01 Payment Team.The due date is:January 17, 2020 5:00 PM.
The priority is: High 12/6/2019 2:11 PM

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1Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System 'D application for•• - .•-under NorthCarolina's
General Permit 1 1111:STORIMATER DISCHARGES associated with construction activities(or
NORTH CAROLINA
Enrlrnnmenfu�Qr�arlry
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* ReNu Life:Traumatic Brain Injury Services
2.County* Wayne
3. Highway or Street 201 Windsor Creek Parkway
Address* Street nacre only is acceptable if no address number assigned yet
4. City or Township* Goldsboro
5.State* NC
6.Zip Code* 27534
7. Latitude* Enter the latitude in decimal degrees
35.4140
8. Longitude* Enter the longitude in decimal degrees(M.ST be negative)
-77.9430
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* 01/06/2020
Estimated Construction Project Start Date
10. Date to End* 12/01/2020
Estimated Construction Project End Cute
11.SIC(Primary)* Commercial(1542)
Standard Industrial Classification for Development
12.Acres to be 2.90
disturbed* (including off-site borrow and waste areas)
13.Total site area 4.52
(acres)*
14. Post- 1.20
construction (Estimated)
impervious area
(acres)*
NCC Project NCC-WAYNE-2020-ReNu Life:Traumatic Brain Injury Services
Tracking ID Assigned automatically

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 Reedy Branch
Waterbody* %rre of waterbody into which storrrwater runoff will discharge
15b.Waterbody 27-62-2
Index No.* NCWaterbody Index N nber
Stormwater r No
discharges will flow Pf Yes
to additional
wate rs*
15c.Additional Stoney Creek
Receiving Waterbody narre
Waterbody
15d.Waterbody 27-62
Index No. NCWaterbody Index Narrber
15e.Additional Waterbody narre
Receiving
Waterbody
15f.Waterbody NCWaterbody Index Number
Index No.
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. ^
F2rnittee Inforrration-Legally Fbsponsible 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 ReNu Life Extended, Inc
Name*
2. First Name* Diane
ff Corporation,enter Fbgistered Agent First Barre
3. Last Name* Harrison
ff Corporation,enter Faegistered Agent Last%rre
3b.Title CEO
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-734-0266
Telephone No.*
6. Permittee Mailing Street Address
Address* 501 Forest Hill Drive
Address Line 2
City State/F rovince/Faegion
Goldsboro NC
Fbstal/Zip Code Country
27534-1824 us
Check box if the rJ Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address* 501 Forest Hill Drive
Address Line 2
City State/Frovince/Fbgion
Goldsboro NC
Fbstal/Zip Code Country
27534-1824 us

C. Site Contact Information
Part C. ^
Roject Site Contact Inforrration
.......................................................................................................................................................................................................................................................................................................................................................................................
1.Type of Non-Government
Ownership*
2. Primary Site Trent
Contact-First
Name*
3. Primary Site Wise
Contact-Last
Name*
4.Title Superintendent
5.Site Contact E- [e-mail]
mail Address*
6.Site Contact 919-920-7583
Telephone No.*
7.Organization Daniels&Daniels Construction Co, Inc.
Name
8.Site Contact Street Address
Mailing Address* PO Box 10337
Address Line 2
City State/Rovince/Region
Goldsboro NC
Fbstal/Zip Code Country
27532 us
9. Consultant Name (Optional)
Rudy Tietje
First and Last narre
10. Consultant E- [e-mail]
mail This person will be copied on all correspondence.
11. Consultant 919-750-3123
Telephone No.

D. E&SC Plan
Part D. ^
Erosion&Sediment Control(E&SC)Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 11/18/2019
Approved*
2. E&SC Plan Project Wayne-2020-008
Number/ID* Assigned by agency or local program
3. E&SC Plan r State DEQ Office
Approved by* r Local Program
4.State DEQ Office* Washington (WaRO)
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 Wayne-2020-008 Renu-Life- 11182019 DEQ
Approval 1.18MB
Approval.pdf
letter/documentation
Mist be R7Fforrrat
6. NOI Certification ReNu Life NOI.pdf 1.01 MB
Form Mist be R7Fforrrat
This is an Express f No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6E(i) 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 knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Artcle;or who falsifies,tampers with,or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
Commission implementing this Artcle 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:
17 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.
* 17 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
f 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 )/
Gl7611° ` '74't.1v/ve
Type Name* Diane Harrison
Title CEO
Organization ReNu Life Extended, Inc.
Date* 12/04/2019

F. Tracking and COC Info
NOI Tracking No. 19121
NC Reference No. NCG01-2019-3100
Uses'count_nurrber'variable(increrrented by SP)
Certificate of NCC193100
Coverage (COC) Uses'count number'variable(increrrented by SP)
No.*
Count Number 3100
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2019
Year of date reviewed(used to assign YY digits after"NOC'in COCno.)