NCC200197_NOI Signed Certification_20200123

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
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).
Uncle:{{ enalty of law, I certify that (check all boxes to indicate your agreement):
1 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.
The information submitted in this N01 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
f directly responsible for gathering the information.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
N/ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
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.
Name of Project:. Tabor City PK-8 Grade School Abatement Demolition + Soils Remediation (Tabor City Surcharge)
Legally Responsible Organizational Entity: Columbus County Schools
Legally Responsible Person: Jonathan Williams
Title of Legally Responsible Person: Associate Superintendent
*Signature: Date:
*Print Na e d Title of Signed if Authorized
Individu iffers from Permittee:
Phone Number: 910-642-5168
* 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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.

1/16/2020
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NORTH CAROLINA
Enyt nnmenrcr Quartry
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 I B. Permiltee Information I C_ Site Contact information I D. E&SC Plan
E. Certification
Part A.
Project Location and Walerbody Information
-....._.__.... ---
1. Project Name's abor City PK 8 Grade School Abatement Demolition + Soils Rem(
2. County* I Columbus
I
3. Highway or Street 03 Stake Rd
Address * Street name only is acceptable if no address number assigned yet
4. City or Township* abor City
5. State* NC
6. Zip Code* 8463
7. Latitude * Enter the latitude in decimal degrees
4.1519
8. Longitude* Enter the longitude in decimal degrees (MUST be negative)
78.8739
If you do not know the latitude and longitude coordinates for this project, you can search the location on this map of
North Carolina (https-//ncdenr.maps.arcgis.com/apps/webappviewer/index.htmi?
id=9fdfc3872651444c8339d718a099a1ac). look for the coordinates in the bottom left corner.
9. Date to Begin* 04/01 /2020
Estimated Construction Project Start Date
10. Date to End* 12/01/2020
Estimated Construction Project End Date
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11. SIC (Primary)* Commercial (1542
Standard Industrial Classification for Development
12. Acres to be .00
disturbed* (including off -site borrow and waste areas)
13. Total site area 11.31
(acres) *
14. Post- 1.84
construction (Estimated)
impervious area
(acres) *
Project Tracking ID NC(;-COLUM-2020-Tabor City PK-8 Grade School Abatement Den
Assigned automatically
Below you must enter waterbody information for surface waters affected by this project. Please consult
DWR's Surface Water Classifications Map Viewer (https:Hncdenr.maps.arcgis.com/apps/webappviewer/index.htmi?
id=6e125ad7628f494694e259c80dd64265) 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 own Canal
Waterbody* Name of waterbody into which slormwater runoff will discharge
15b. Waterbody 115-17-1-6
Index No.* NC Waterbody Index Number
Stormwater : i No
discharges will flow :v Yes
to additional waters*
15c. Additional immons Branch
Receiving Waterbody name
Waterbody
15d. Waterbody 15-17-1-4
Index No. NC Waterbody Index Number
15e. Additional I
Receiving Waterbody name
Waterbody
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15f. Waterbody Index
No. NC Waterbody Index Number
16a. Is this project Yes
subject to the NC No, not subject to NC SPCA
Sediment Pollution
Control Act?*
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NORTH CAROLINA
14in*wusm1of Qualfty
Construction Stormwater: Notice of Intent (NQI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North Carolina's
General Permit NCG010000: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
A. Project Information I B. Permittee Information I C. Site Contact information I D. EBSC Plan
E. Certification
Part B.
Permitlee Information - Legally Responsible Entity and Individual
.. ..... ... ...... .................. ..... ......... ........
Important: The person who signs the N01 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 NCGO10000 General Permit. For more information on signatory requirements, see Part
IV, Section B, Item (6) of that permit.
1.Organization Columbus County Schools
Name*
2. First Name*
onathan
If Corporation, enter Registered Agent First Name
3. Last Name*
illiams
If Corporation, enter Registered Agent Last Name
3b. Title *
ssociate Superintendent
4. Permitee E-mail
'[e-mail]
Address *
------- ----- -----
5. Permittee 10-642-5168
Telephone No.*
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6. Permittee Mailing Street Address
Address` 17 Washington St
Address Line 2
Check box if the
street address the
same as mailing
address
City
Phiteville
Postal / Zip Code
8472
!� Yes
7. Permittee Street Street Address
Address* 17 Washington St
Address Line 2
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State 1 Province 1 Region
T rNC
Country
US
City
State / Province 1 Region
hiteville
NC
Postal I Zip Code
Country
8472
U5
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1/16/2020
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NORTH CAROLINA
F.Avlronr"nta1 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 I B. Permittee Information I C. Site Contact information I D. E&SC Plan
E. Certification
Part C.
Project Site Contact Information
1. Type of Government - Federal •
Ownership
2. Primary Site onathan
Contact - First
Name*
3. Primary Site �1lilliams
Contact - Last
Name*
4. Title Associate Superintendent
5. Site Contact E-
[e-mail]
mail Address*
This person will be copied on all correspondence.
6. Site Contact
10-642-5168
Telephone No.*
7. Organization lColumbus County Schools
Name
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8. Site Contact Street Address
Mailing Address* 17 Washington St�
Address tine 2
City
State 1 Province 1 Region
hiteville
NC
Postal 1 Zip Code
Country
8472
US
9. Consultant Name
10. Consultant E-
mail
11. Consultant
Telephone No.
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(Optional)
Lauren Dickson
First and Last name
[e-mail]
This person will be copied on all correspondence.
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A 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
p
+.-P 91 NCG250000)
NORTH CAROL INA — -- -- l
Envlronn MMIQUOINY A. Project Information I B. Permittee Information C. Site Contact information D. E&SC Plan
E. Certification
Part D.
Erosion & Sediment Control
(E&SC) Plan Approval Information
1. Date E&SC Plan
11/04/2019
Approved*
2. E&SC Plan Project
6OLUM-2020-004
Number/ID*
Assigned by agency or local program
3. E&SC Plan
+; State DEQ Office
Approved by*
Local Program
4. State DEQ Office*
Wilmington Regional Office (WiRO) • '.
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form
(https://fi les. nc.gov/ncdeq/Energy%2OMineral%20and%2OLand%2OResources/Stormwater/NPDES
eNOI-Certification-Form-20190919-DEMLR-SW.pdf) is required for a complete application.
5. E&SC Plan Upload I
Approval COLUM-2020-004 Approval 11 -4-201 9.pdf (/Forms... 298.42KB x
letter/documentation *
Must be PDF format
6. NOI Certification UPload
Form * Must be PDF format
YOU MUST MAIL THE ORIGINAL SIGNED NOI CERTIFICATION FORM (click on this link)
(https:/Ifiles.nc.gov/ncdeq/Energy%20Mineral%20and%20Land%20Resources/Stormwater!NPDES%20General%20Pei
eNOI-Certification-Form-20190919-DEMLR-SW.pdf) to The Stormwater Program at the address on the form for the
application to fulfill federal application requirements. The Certification Form must be signed by the person listed in Section
B (Permittee 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 Express No
Review Project* Yes
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its/N
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NORTH CAROLINA
f nvftmwnrcf QaoNty
Construction Stormwater: Notice of Intent (Not)
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 I B. Permittee Information I C. Site Contact information I D. E&SC Plan
E. Certification
North Carolina General Statute 143-215.6E (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:
:,."I 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.
✓i 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 I will abide by all conditions of the NCGO10000 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 are: The Responsible Person named on this Notice of Intent
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
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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 NCGO10000 General Permit. For
more information on signatory requirements, see Part IV, Section B, item (6) of that permit.
Signature*
Type Name*
Title
Organization*
*
g f [_.0 Gt JYi c4uit �% � Q
Date* Date captured on form submission
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