NCC233121_NOI Signed Certification_20231019

NCGO1 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 $120 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
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
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).
Under enalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
IPermit, 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
athering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Ian.
the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
If n
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.
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.
t match Ala): l .6 �S y [J l-A 5e-) GA ...�Pro�ectName (mus ) � S� Q
Specific Lot Numbers (must match Alb):
Permittee (must match B1 ): e GA c-y of Aj7 Ed 64 S-rn )r4 Z., 6 C
i
Legally Responsible Person (must match 82 & 83): A wi I -G (_j i?
Title of Legally Responsible Person (must match B3b): 014AJ4 6.€A...,
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: ' 7 QOç 0 3 3 LC.
/ ob.-)
c2 47
'----- Signature of Legally Responsible Person or Authoriz ndividual Da e
* 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 B,
Item (6) of the NCG010000 permit.

NCGO1 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 $120 check if paying by check)
at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22)
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).
Under enalty of law, I certify that (check all boxes to indicate your agreement)
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
ermit, 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
2athering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Ian.
the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution If n
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.
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.
Project Name (must match Ala): 1— i 7 7U1-11 5e- GA 6-7--(5)4)..-c4
Specific Lot Numbers (must match A1b):
Permittee must match B1): e 6A G ?ay:�V`f e-' V4 cc`I-nor-4 L G C( Y
.
Legally Responsible Person (must match B2 & B3): A wi i -ei W
Title of Legally Responsible Person (must match 83b): 014A1/4..)4 ( . I' ..
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: ' () y qe) C 0 3 3LC
/O`17 c �
Signature of Legally Responsible Person or Authoriz ndividual Da e
* 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 B,
Item (6) of the NCG010000 permit.

NCGO1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $120 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
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
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).
Under enalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
ermit, 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
2athering the information.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Ian.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the NCGO10000 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.
Project Name (must match Ala): I �1-- csa-rdLQ 5e_J GA 6---rov.. .(1
Specific Lot Numbers (must match Alb):
Permittee (must match 81): GAG' GA Gy ?sOCE-A-,>e' 64 rrn 0..E-44 j L G C •
Legally Responsible Person (must match 82 & 83): � A ►�n 1 �i
Atf„,„, ,
Title of Legally Responsible Person (must match B3b): frø4A.... 4 6.6t..
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 7O ' / Qoç 033 ¼�T
3
______
/ 01n 72
Signature of Legally Responsible Person or Authoriz ndividual Date
* 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 B,
Item (6) of the NCG020000 permit.

NCGO1 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 $120 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
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
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).
Under enalty of law, I certify that (check all boxes to indicate your agreement)
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
ermit, and for any civil or criminal penalties incurred due to violations of this permit.
E(13
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
2athering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Ian.
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 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.
Project Name (must match Ala): l7 &U/-4 c 5 J GA s-j ,,q
Specific Lot Numbers (must match Alb):
Permittee (must match 81): L. G GA cy ?OA3r CA �`T''C)r.l L G C ,
I l
.
Legally Responsible Person (must match B2 & B3): A wi i -G (,o G�
Title of Legally Responsible Person (must match 83b): 014ivg 6 _,
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: ' 7 0 / �'j O Q 3 3
0/1 ecp (7
Signature of Legally Responsible Person or Authoriz ndividual Da
* 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 NCG010000 permit.

NCGO1 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 $120 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
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
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).
Under enalty of law, I certify that (check all boxes to indicate your agreement)
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
ermit, 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
2I
athering the information.
will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Ian.
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 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.
Project Name (must match Ala): 1-- I re cS 7 - (. GA 6-2-a�zr.,Q
Specific Lot Numbers (must match Alb):
Permittee (must match 81): e GAGY ?O-.2-. ...-3-7-e-, 64 r )_EA G G C
1
Legally Responsible Person (must match 82 & 83): � A ►.,l 1 -e. POI 'e.1.0 1•02
Title of Legally Responsible Person (must match B3b): 014&,Vq (s .�
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: —2 0 qo c D 3 3 LC.
J
l o(1-) c
Signature of Legally Responsible Person or Authoriz ndividual Da e
* 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 B,
Item (6) of the NCG010000 permit

NCGO1 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 $120 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
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification in ony 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).
Under enalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
ermit, and for any civil or criminal penalties incurred due to violations of this permit.
he information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and complete
T e
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
2athering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Ian.
the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
If n
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.
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.
Project Name (must match Ala): Z- 17 c[1 L' 5e--) GA 6-7-6 , 41
Specific Lot Numbers (must match Alb):
Permittee (must match B1 : L G GA G ?O23 f 6 ‘S`r'CJx) G C
1
...._. , p Legally Responsible Person (must match B2 & B3): A wi t -e, w �G,
Title of Legally Responsible Person (must match B3b): 014AJ44 6-(A__,
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: `7 0 `T Q U c 0 3 3 S.--
_____ /D`l--)Signature of Legally Responsible Person or Authoriz ndividual Da(c2 ,?
* 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 NCG010000 permit.

NCGO1 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 $120 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
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
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).
Under enalty of law, I certify that (check all boxes to indicate your agreement)
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
ermit, 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
2 athering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Ian.
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 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.
Project Name (must match Ala): 1.- lb
U 1Q l3 -) GA S7 Q
Specific Lot Numbers (must match Alb):
Permittee (must match B1): G GA Cy Par:Aire---' 64 c547-1dX.)r-4 L G C .
1
.
Legally Responsible Person (must match 82 & 83): A ' : I ,G bo (J�
Title of Legally Responsible Person (must match B3b): 0l4I%J4 6re.,l_,
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: '2 pt./ qvc 0 3 3 T
/01/ � �
Signature of Legally Responsible Person or Authoriz ndividual Da e
* 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 B,
Item (6) of the NCG010000 permit.

NCGO1 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 $120 check if paying by check)
at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6t" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22)
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).
Under enalty of law, I certify that (check all boxes to indicate your agreement)
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
ermit, 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
athering the information.
Ezi
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
2IfIan.
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 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.
Project Name (must match Ala): l � (J U 5(-) GA 6-6-7 q
Specific Lot Numbers (must match Alb):
Permittee (must match 81): G-• e GA Gy POL.,-..5.A_,-re-, 6.4 s`T-C ),T.4 L G C .
i
Legally Responsible Person (must match 82 & 83): A �.,1 I -i /�
g y P w
Title of Legally Responsible Person (must match B3b): 014AJ4 6-(A__.
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: ' ? 0 goc 0 3 3 LC-
o`1� c9
Signature of Legally Responsible Person or Authoriz ndividual Da e
* 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 B,
Item (6) of the NCG010000 permit.