NCC216564_NOI Signed Certification_20211201

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Thin, mail the original form to the NC ❑EMIR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral &Land Resources Stormwater Program
512 N. Salisbury Street, 6,1 Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NET
MAID.
THIS
FARM
DR
PAYMENT L1NT1L YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FARM
YOU
MAIL
MUST
BE
COMPLETED WITH AN ORIGINAL SIGNATURE SNOT DIGITAL) [40 CFR 122.221
Per NC General Statute 343-215.68 (i), any person who kn o win g /y makes any false statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article or cr rude implementing this Article ... sha11 b e guilty of a Class 2 misdemeanor which may include a fine nat to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement). -
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 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 NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met an 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 hermit.
Name of Project (must match Ada): Prose University
Specific Lot Numbers (must match A1b):
Legally Responsible Organizational Entity (must match 131}: Alliance Real Partners, LLC
Legally Responsible Person (must match B2 & B3): shad Platt
Title of Legally Responsible Person (must match Bab):
Name Sc Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number:
704-728-9706
Vice President
Signature of Legally Responsible Person or Authorized Individual Date
IMPORTANTNOTE.- This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president., .secretary, treasurer, or rice president, or o manager thGt is authorized in accordance with Part IV, Section B,
Item (6) of to NCGO10000 permit.