SW5230902_Application Form_20240103

As the legal property owner I acknowledge,understand,and agree by my signature below,that if my designated
agent(entity listed in Contact Information,item 1)dissolves their company and/or cancels or defaults on their
lease agreement,or pending sale,responsibility for compliance with the DEMLR Stormwater permit reverts back
to me,the property owner. As the property owner,it is my responsibility to notify DEMLR immediately and
submit a completed Name/Ownership Change Form within 30 days;otherwise I will be operating a stormwater
treatment facility without a valid permit. I understand that the operation of a stormwater treatment facility
without a valid permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement
action including the assessment of civil penalties of up to$25,000 per day,pursuant to NCGS 143-215.6. 2
Signature: Date: C6\CI I?t 3
I, M Ck l O V VWC)---"------ ,a Notary Public for the State of NC,C ,County of
('& I n ,do hereby certify that bt)I(2P� Su 1� personally appeared
before me this day of l 1V�v Ion ,and knowledge t e d e�exxeccution of the application for
a stormwater permit. Witness my hand and official seal, "" u
, ttiiirPNID!lp4,"�� SEAL
.. .,e
Notary Public q Franklin County My commission expires \u\?PI
X. APPLICANT'S CERTIFICATION y���
I, (print or type name of person listed in Contact Information, item 1a) bolobki1 1 wit('Sw ' ,
certify that the information included on this permit application form is,to t e best of my knowledge,correct and
that the project will be constructed in conformance with the approved plans,that the required deed restrictions
and protective covenants will be recorded,and that the proposed project complies with the requirements of the
applicable stormwater rules under 15A NCAC 2H.1000 and any other applicable state stormwater requirements.
Signature: (116,A Date:S O 1 2-o 13
I, 'V V Xi I OV. ,a Notary Public for the State of C' ,County of
Prow IA 1 nq ,do hereby certify that iSo Y/� coin V personally appeared
before me this VI of !%ic' 1/�,and acknowled0
ge the due exe ution of the application for
a stormwater permit. Witness my hand and official seal, ��T V
\ \\` oo
Cop'NID100�S .
SEAL
wool Public
i Franklin County `off 1���oa'1
Q My commission expires
ry""yo A�H CR ;��,
Form S WU-10l Version Oct. 31,2013 Page 6 of 6