NCC200149_NOI Signed Certification_20200114

Pr nt this form, complete, scan and upload to the eieciroti . W-)'.
Then, mail the original form to the NC DEMI R Stormwater Program (,with $100 check ifpaying by been; at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
A;
Per ,NC General Statute 143-215.68 (I), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
�J 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.
DO 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.
® I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit. I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
I hereby request coverage under the NCGO10000 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.
Responsible Organizational Entity: Matcor Metal Fabrication, Inc.
Iv Responsible Person: John
Title of
`Signature: _ -t*-�
*Print Name and Ti of Signed if Author
Individual Differs fr m Permittee: John
Phone Number: 905-814-7479
e, President
Date: a ,ti .
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that 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 8, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.

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NORTH CAROLINA
Envirommenia/ Quality
Construction Stormwater: Notice of
Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage
under North Carolina's General Permit NCGO10000: STORMWATER DISCHARGES
associated with construction activities (or NCG250000)
A. Project Information
Part A.
Project Location and Waterbody Information
1. Project Name* Matcor Metal Fabrication Site Improvements
2. County* Davidson
3. Highway or 835 Salem Road
Street Address * Street name only is acceptable if no address number assigned yet
4. City or
Township*
5. State*
8. Longitude*
Welcome
NC
27374
35.8958
Enter the longitude in decimal degrees (MUST be negative)
-80.2525
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* 01/20/2020
Estimated Construction Project Start Date
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10. Date to End * 04/30/2020
Estimated Construction Project End Date
11. SIC (Primary) Commercial
* (1542)
Standard Industrial Classification for Development
12. Acres to be 3.66
disturbed* (including off -site borrow and waste areas)
13. Total site area 32.11
(acres) *
14. Post- 10.07
construction (Estimated)
impervious area
(acres)*
Project Tracking NCC-DAVID-2020-Matcor Metal Fabrication Site
ID Improvements
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 Easter Creek
Waterbody * Name of waterbody into which stormwater runoff will discharge
15b. Waterbody 12-119-8-4-1
discharges will ❑ Yes
flow to additional
waters *
16a. Is this Q Yes
project subject to O No, not subject to NC SPCA
the NC Sediment
Pollution Control
Act? *
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B. Permittee Information
Part B.
Permittee 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
Name *
2. First Name*
3. Last Name*
3b. Title *
4. Permitee
E-mail Address*
6. Permittee
Telephone No.*
Mailina Address*
Check box if the
street address
the same as
mailing address
Matcor Metal Fabrication, Inc.
John
If Corporation, enter Registered Agent First Name
Bogoje
If Corporation, enter Registered Agent Last Name
President
[e-mail]
905-814-7479
Address Line 2
City
Lexington
Postal / Zip Code
27295-1086
0 Yes
State / Province / Region
NC
Country
us
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7. Permittee
Street Address
835 Salem Road
Lexington
Postal / Zip Code
27295-1086
State / Province i Region
NC
Country
us
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C. Site Contact information
Part C.
Project Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Tony
Contact - First
Name *
3. Primary Site Coomer
Contact - Last
Name *
4. Title Director of Operations
5. Site Contact [e-mail]
E-mail Address* This person will be copied on all correspondence.
6. Site Contact 336-731-5783
Telephone No.*
7. Organization Matcor Metal Fabrication, Inc.
Name
8. Site Contact Street Address
Mailing Address* 835 Salem Road
City
Lexington
Postal / Zip Code
27295-1086
State / Province /
NC
Country
US
9. Consultant (Optional)
Name L. Allan Hill, PE/Triad Design Group, PC
First and Last name
10. Consultant [e-mail]
E-mail This person will be copied on all correspondence.
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11. Consultant 336-218-8282
Telephone No.
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D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Plan Approval Information
1. Date E&SC 10/07/2019
Plan Approved*
2. E&SC Plan David-2020-014
Project Assigned by agency or local program
Number/ID*
3. E&SC Plan O State DEQ Office
Approved by* Q Local Program
4. State DEQ Winston-Salem Regional Office
Office * (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 DOC100719-10072019143715.pdf 11.24MB
Approval Must be PDF format
letter/documentation *
6. NOI Construction Stormwater_ Notice of Intent (NO... 70.64KB
Certification Must be PDF format
Form *
Stormwater Program at the address on the form for the application to fulfill federal application
Information) or by an authorized responsible person within the same organization. NOTE: The
person who signs the paper form must be the same person to electronically certify and sign
the eNOI.
This is an O No
Express Review * Yes
Project*
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E. Certification
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report,
plan, or other document filed 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 under this Article; 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 Article shall be guilty of a Class 2
misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
* rs-/] 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.
* W 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.
* F I will abide by all conditions of the NCG010000 General Permit and
the approved Erosion and Sediment Control Plan.
* 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 Q The Responsible Person named on this Notice of Intent
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*
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Submission Completed
Type Name* John Bogoje
Page 9 of 9
Title * President
Organization * Matcor Metal Fabrication, Inc.
Date * 01 /13/2020
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