NCC210642_NOI Application_20210219

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/1/2021 3:50:07 PM (NCG01 NOI Submission)
Approve by Meloy, Michael 2/2/2021 8:47:35 AM (Review- Construction NOI 42537)
• The task was assigned to Meloy, Michael by round robin distribution 2/1/2021 3:50 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 3, 2021 5:00
PM 2/1/2021 3:50 PM
Submit by McCoy, Suzanne 2/19/2021 7:56:08 AM (Payment Verification for NCC210642)
* Cindy Hensley
• McCoy, Suzanne assigned the task to McCoy, Suzanne 2/19/2021 7:55 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: March 16, 2021 5:00 PM
2/2/2021 8:48 AM

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1
NORTH CAROLINA
EnrlronmertW quallly
A. Project Information
Part A.
Project Location and Waterbody Information
Are you submitting IT No
an NOI that was r Yes
rejected before?
1a. Project Name * CaroMont Regional Medical Center - Belmont
1 b. Specific Lot This field rray be used to list specifc lot nunbers.
Numbers
1 c. Parcel ID List all Rim associated w ith this project.
Number(s) (PIN) 301922
2. County* Gaston
3. Highway or Street 1-85 and NC-273
Address* Street name only is acceptable if no address nunber assigned yet
4. City or Township* Belmont
5. State * NC
6. Zip Code* 28012
7. Latitude* Enter the latitude in decinal degrees
35.2581
8. Longitude * Enter the longitude in decinal degrees (MJSTbe negative)
-81.0323
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*
03/01/2021
Estir ated Construction Project Start Late
10. Date to End *
06/01 /2023
Estinated Construction Project End Date
11. SIC (Primary)*
Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be
42.00
disturbed*
(including off -site borrow and waste areas)

13. Total site area 292.61
(acres) *
14. Post- 16.27
construction (Estimated)
impervious area
(acres) *
NCC Project NCC-GASTO-2021-CaroMont Regional Medical Center - Belmont
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 Catawba River
Waterbody* Narreof waterbody into which storrrwater runoff will discharge
15b. Waterbody 11-(117)
Index No. * NCWaterbody Index Nurrber
Stormwater V 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. ^
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 Legally Pesponsible Entity
Name * CaroMont Health, Inc.
It pernittee is an individual (i.e., organization does not apply), enter first and last narre in this field.
Note: The organization name must match the business entity name registered with the NC Secretary of State. You can
verify the registration here.
2. First Name * Richard
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Blackburn
It Corporation, enter Pbegistered Agent Last %rre
3b. Title Vice President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 7048342233
Telephone No.*
6. Permittee Mailing Street Address
Address* 2525 Court Drive
Address Line 2
City
Gastonia
Fbstal / Zip Code
28054-2140
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
V Yes
Street Address
2525 Court Drive
Address Line 2
city
Gastonia
Fbstal / Zip Code
28054-2140
State / Frovince / Fbgion
NC
Country
us
State / Frovince / Faegion
NC
Country
us
8. Type of Ojvnership is only individual if an individual is naned in B.1. above.
Ownership* Non -Government

C. Site Contact Information
Part C.
Project Site Contact Inforrration
....................................................................................................................................................................................................
1. Primary Site
Dave
Contact - First
Name *
2. Primary Site
Hultstrand
Contact - Last
Name *
3. Title
Senior Superintendent
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
205-381-9804
Telephone No.
6. Organization
Robins & Morton Company, LLC
Name
7. Site Contact
Street Address
Mailing Address*
173 Beatty Drive
Address Line 2
City
Belmont
Postal / Zip Code
28012
8. Consultant Name
(Optional)
Mark McAuley
First and Last narre
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person a-rrail
12. Billing
(For Annual Fee correspondence)
Telephone
7048342233
Default is legally responsible person telephone
State / Province / 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 12/29/2020
Approved *
2. E&SC Plan Project 3690
Number/ID * Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by* r Local Program
4. Local Program* Gaston County
Documentation of E&SC Plan approval and the signed Notice of Intent (NOI) Certification Form is required for a
complete application. Please also upload a site map showing the overall extent of the project (for linear projects, can
include the beginning point and end point coordinates in the "Notes" box below).
5. E&SC Plan Caromont SE&SC Approval.pdf 329.84KB
Approval letter or Mast beRDFformat
Grading Permit
6. Site Location Map Mist be RDFforrrat (lint 20 NB)
4643_CRMC_Site Location_02.01.21.pdf 582.38KB
Rease do not upload entire set of E&SC plans.
7. Notes (Optional) Rovide any additional information that night help the reviewer better understand how uploaded documents support
the application. Include additional waterbodies if necessary.
8. NOI Certification NCG01 Notice of Intent Certification Form CaroMont
Form 345.07KB
Regional Medical Center - Belmont 02012021.pdf
Mast be FDFfon-rat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse 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 Atide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this Atcle; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Amide or rules of the
Commission implementing this Atcle shall be guilty ofa Class 2 misdemeanor which may include 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 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.
* 17 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 Legally Responsible Person named on this Notice of Intent
f Authorized Responsible Person' (signing on behalf of Legally Responsible
Person named in Part B)
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* Richard Blackburn
Title Vice President
Organization Legally Ibsponsible Entity
CaroMont Health. Inc.
Date * 02/01 /2021

F. Tracking and COC Info
NOI Tracking No. 42537
NC Reference No.
NCG01-2021-0642
Uses 'count_nurrber' variable (increrrented by SP)
Certificate of
NCC210642
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 642
Sequential nurrber for subrrittal that is incremented by Stored Frocedure
COC Year 2021
Year of date reviewed (used to assign YY digits after "NOC' in COCno.)
Initial Invoice No. NCC210642-2021
Invoice Due Date 3/4/2021
Initial Fee $ 100.00
Invoice Status OPEN