NCC201820_NOI Signed Certification and Authorization_20200511

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) a
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL Y UR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS OMPLETE
Per NC General Statute 143-215.6E (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 penalty of law, I certify that (check all boxes to indicate your agreement):
0 1 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.
N The information submitted in this NO[ is, to the best of my knowledge and belief, true, accurate, ar
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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 NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
0 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 11 of the permit are met on the project at all times.
N I hereby request coverage under the NCGO10000 General Permit and understand that coverage un
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this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: Beach Bum
Legally Responsible Organizational Entity: Beach Bum, LLC.
Legally Responsible Person: Tam Athey
Title of Legally Responsible Person: Mpipber,
_..._ f
*Signature:
`zm%► ALL Date:
*Print Name and Title of Signed if Authorized
individual Differs from Permittee:
Phone Number: 704-614-1262
* 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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, item (6) of the NCG010000 permit.

THE LAW OFFICE OF ERIK B. BLOWERS
ERIK B. BLOWERS, ATTORNEY
WWW.IFWLAWGROUP.COM
January 25, 2020
North Carolina Department of Environmental Quality
Division of Energy, Mineral and Land Resources
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, N.C. 28405
Dear Sir or Madam:
AN INDEPENDENT LAW PRACTICE
Office: 704.607.8870
Fax: [phone]
E-MAIL: I [e-mail]
I am a member, the organizer and the registered agent of Beach Bum, LLC, which was
filed under the laws of the State of North Carolina and registered with the Secretary of State
on May 23, 2019. I understand that a question has arisen with regard to authority to act on
behalf of the corporate entity, organized as an LLC in the State of North Carolina.
Mr. Tom Athey, home address of 81 W. 2nd Street, Ocean Isle Beach, North Carolina is
also a member of the limited liability corporation and has full and complete authority to act on
behalf of and as a representative of the corporation for all purposes. Should any question
arise with regard to this issue, I may be contacted at our office at [phone].
In advance, we thank you for your assistance in this matter.
Very Truly Yours,
�TB.—ff�
Erik B. Blowers
P.O. Box 79194 1 CHARLOTTE, NC 28271
*ERIK B. BLOWERS IS LICENSED IN NORTH CAROLINA & OHIO (INACTIVE); MARTIN L. KAPLAN LICENSED IN NORTH CAROLINA