NCC212068_NOI Application_20210406

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/2/2021 1:58:31 PM (NCG01 NOI Submission)
Approve by Garcia, Lauren V 4/5/2021 10:31:18 AM (Review- Construction NOI 49565)
• The task was assigned to Garcia, Lauren V by round robin distribution 4/2/2021 1:59 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: April 6, 2021 5:00 PM
4/2/2021 1:59 PM
Submit by Selkane, Aziza 4/6/2021 8:53:56 AM (Payment Verification for NCC212068)
* Eric Brown
• Selkane, Aziza assigned the task to Selkane, Aziza 4/6/2021 8:47 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: May 17, 2021 5:00 PM
4/5/2021 10:31 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 *
Upper Piedmont Renewable Natural Gas Plant site
1 b. Specific Lot
This field may be used to list specifc lot numbers.
Numbers
7044
1 c. Parcel ID List all Rios associated w ith this project.
Number(s) (PIN) 0953-00-05-7044
2. County* Person
3. Highway or Street 9650 Oxford Road
Address* Street name only is acceptable if no address number assigned yet
4. City or Township* Rougemont
5. State * NC
6. Zip Code* 27572
7. Latitude* Enter the latitude in decimal degrees
36.3168
8. Longitude * Enter the longitude in decimal degrees (MJSTbe negative)
-78.8284
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*
04/01/2021
Estimated Construction Project Start Rate
10. Date to End*
10/11/2021
Estinated Construction Project End Date
11. SIC (Primary)*
Industrial (1541)
Standard Industrial aassification for Development
12. Acres to be
21.20
disturbed*
(including off -site borrow and waste areas)

13. Total site area 21.20
(acres) *
14. Post- 4.00
construction (Estirreted)
impervious area
(acres) *
NCC Project NCC-PERSO-2021-Upper Piedmont Renewable Natural Gas Plant
Tracking ID site
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 Unnamed Tributary of Cub Creek
Wate rbody* f\brre of waterbody into which storrrwater runoff will discharge
15b. Waterbody 28-3
Index No. * NCWaterbody Index Nurrber
Stormwater P 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 * Upper Piedmont Renewables LLC
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 * David
If Corporation, enter Faegistered Agent First %rre
3. Last Name* Wentworth
It Corporation, enter Pbegistered Agent Last %rre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 541-549-8766
Telephone No.*
6. Permittee Mailing Street Address
Address* 13418 Trillium GM 420
Address Line 2
City
Black Butte Ranch
Fbstal / Zip Code
97759
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
F Yes
Street Address
15820 Barclay Dr
Address Line 2
city
Sisters
Fbstal / Zip Code
97759
State / Frovince / Fbgion
OR
Country
United States
State / Frovince / Faegion
OR
Country
United States
8. Type of Ownership is only individual if an individual is naned in B.1. above.
Ownership* Non -Government

C. Site Contact Information
Part C.
Roject Site Contact Inforrration
...........................................................................................
1. Primary Site Eric
Contact - First
Name *
2. Primary Site Brown
Contact - Last
Name *
3. Title
Project Engineer
4. Site Contact E-
[e-mail]
mail Address*
5. Site Contact
5419045036
Telephone No.
6. Organization
Upper Piedmont Renewables LLC
Name
7. Site Contact
Street Address
Mailing Address*
15820 Barclay Dr
Address Line 2
city
Sisters
Postal / Zip Code
97759
8. Consultant Name
(Optional)
K. Matthew Cheek
First and Last nave
9. Consultant E-mail
[e-mail]
This person will be copied on all correspondence.
10. Consultant
4787437175
Telephone No.
11. Billing E-mail
(For Annual Fee correspondence)
[e-mail]
Default is legally responsible person e-nail
12. Billing
(For Annual Fee correspondence)
Telephone
541-549-8766
Default is legally responsible person telephone
State / Rovince / Region
OR
Country
United States

D. E&SC Plan
Part D. ^
Erosion & Sediment Control (E&SC) Ran Approval Information
......................................................................................................................................................................................................................................................................................................................................
1. Date E&SC Plan 03/26/2021
Approved *
2. E&SC Plan Project Perso-2021-010
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 * Raleigh (RRO)
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 PERSO-2021-010_20210326_LOA.pdf 256.79KB
Approval letter or Mast beRDFformal
Grading Permit
6. Site Location Map Mist be RDFforrret (lint 20 NB)
Landfill Location Map_rev2020 v1_O.pdf 865.25KB
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 docurrents support
the application. Include additional waterbodies if necessary.
8. NOI Certification NOI Certification Form - DW Signed.pdf 498.16KB
Form Wst be RDFforrret
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 Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this 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 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 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:* IT 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 * David R. Wentworth
Title President
Organization Legally Responsible Entity
Upper Piedmont Renewables LLC
Date * 04/02/2021

F. Tracking and COC Info
NOI Tracking No. 49565
NC Reference No.
NCG01-2021-2068
Uses 'count_nurber' variable (increrrented by SP)
Certificate of
NCC212068
Coverage (COC)
Uses 'count_nurrber' variable (increrrented by SP)
No.*
Count Number 2068
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. NCC212068-2021
Invoice Due Date 5/5/2021
Initial Fee $ 100.00
Invoice Status OPEN