NCC190482_NOI Application_20190605

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/5/2019 7:13:13 AM (NCG01 NOI Submission)
Approve by Georgoulias, Bethany 6/5/2019 1:43:40 PM (Review- Construction NOI 11758)
In Confirmed with Chris Morgan that he is an appropriately authorized individual to sign the Certification
for the NOI application and is under the same overall organization entity as the permittee listed.
• The task was assigned to Georgoulias, Bethany by round robin distribution 6/5/2019 7:13 AM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 7, 2019 5:00 PM
6/5/2019 7:13 AM
Submit by Georgoulias, Bethany 6/7/2019 8:07:51 AM (Payment Verification - NCG01-2019-0482)
p Scan of signed certification form from Mr. Clark obtained via email on 6/7/2019 and will be added to the
permit records. **Also, reviewer inadvertently included comments for another eNO1 application on the
previous re view step for this submittal. Those comments should be disregarded. —
The task was assigned to Georgoulias, Bethany. The due date is: June 6, 2019 5:00 PM
6/5/2019 1:43 PM

STME
NORTH CAROLINA
Ernvlronmentol qualily
A. Project Information
Part A.
Project Location and Waterbody Inforrration
1. Project Name * Handee Hugo's
2. County* Guilford
3. Highway or Street 2829 Randleman Rd.
Address * Street name only is acceptable if no address nurrtrer assigned yet
4. City or Township* Greensboro
5. State * NC
1 r-i) iTiT 7i1) M fiIi (-_TiI a 10141
6. Zip Code* 27406
7. Latitude * Enter the latitude in decirral degrees
36.0187
8. Longitude * Enter the longitude in decirral degrees (MIST be negative)
-79.8032
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* 06/11/2019
Estimated Construction Project Start Date
10. Date to End* 02/10/2020
Estimated Construction Project End Date
11. SIC (Primary)* Commercial (1542)
Standard Industrial aassification for Development
12. Acres to be 1.44
disturbed* (including off -site borrow and waste areas)
13. Total site area
1.96
(acres)*
14. Post-
0.82
construction
(Estimated)
impervious area
(acres) *
NCC Project
NCC-GUILF-2019-Handee Hugo's
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. You may
enter up to 3 waterbodies.
15a. Receiving Ryan Creek
Wate rbody* Narre of waterbody into which stormuater runoff will discharge
15b. Waterbody 16-11-14-2-3
Index No. * NCWaterbody Index Number
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.
Perrrittee Information - Legally Responsible Entity and Individual
.....................................................................................................................................................................
h
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 Sampson Bladen Oil Company, Inc
Name *
2. First Name* Haddon
ff Corporation, enter Registered Agent First l\brre
3. Last Name * Clark
Y Corporation, enter Registered Agent Last Barre
3b. Title President
4. Permitee E-mail [e-mail]
Address*
5. Permittee 919-789-7002
Telephone No.*
6. Permittee Mailing Street Address
Address* 3309 Drake Circle
Address Line 2
City
Raleigh
Postal / Zip Code
27607-3332
Check box if the
street address the
same as mailing
address
7. Permittee Street
Address*
fJ Yes
Street Address
3309 Drake Circle
Address Line 2
City
Raleigh
Fbstal / Zip Code
27607-3332
State / Province / Region
NC
Country
us
State / Province / Region
NC
Country
us

C. Site Contact Information
Part C.
Roiect Site Contact Information
1. Type of Non -Government
Ownership*
2. Primary Site Haddon
Contact - First
Name *
3. Primary Site Clark
Contact - Last
Name *
4. Title President
5. Site Contact E- [e-mail]
mail Address*
6. Site Contact 919-789-7002
Telephone No.*
7. Organization
Sampson Bladen Oil Company, Inc
Name
8. Site Contact
Street Address
Mailing Address*
3309 Drake Circle
Address Line 2
City
Raleigh
Rbstal / Zip Code
27607-3332
State / Province / Region
NC
Country
us

D. E&SC Plan
Part D.
Erosion & Sediment Control (E&SC) Ran Approval Information
.......................................................................................................................................................................................................................................
1. Date E&SC Plan 06/05/2019
Approved *
2. E&SC Plan Project 2943
Number/ID* Assigned by agency or local program
3. E&SC Plan f State DEQ Office
Approved by r Local Program
4. Local Program* City of Greensboro
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 NCG01-Approval Letter (2943).pdf 297.85KB
Approval Mist be FDFfornat
letter/documentation
6. NOI Certification NOI Completed form-Handee Hugo's 212.pdf 462.37KB
Form Mist be RDFfornat
This is an Express r No
Review Project* r Yes

E. Certification
North Carolina General Statute 143-215.6B (1) 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 knowinglymakes 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article 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:
rJ 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.
* V 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.
* I7 I will abide by all conditions of the NCG010000 General Permit and the
approved Erosion and Sediment Control Plan.
* V 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.
* I7 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
r Authorized Responsible Person*
Important: The person who signs this Certification above and signs the NOI Certification Form should be the same
person (or authorized responsible person within the same organization) as listed in Section B (Permittee Information)
of this form. *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
qe"'Zr�r.1avr (WI. C?//'?4-11!1
Type Name* Haddon M. Clark
Title President
Organization Sampson Bladen Oil Company, Inc
Date * 06/05/2019

F. Tracking and COC Info
NOI Tracking No. 11758
NC Reference No. NCG01-2019-0482
Uses 'count number variable (incremrented by SP)
Certificate of NCC190482
Coverage (COC) Uses'count_nunber'variable (incremrented by SF)
No. *
Count Number 482
Sequential nunber for subrrittal that is incremented by Stored Procedure
COC Year 2019
Year of date reviewed (used to assign YY digits after "NGC' in OOCno.)