NCC203645_NOI Signed Certification_20200824

i CG01 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 $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAlI.THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLET
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 fen thousand dollars ($10,000).
Under penalty of law, I certify ghat (check all baxes to indicate you,., agreement):
E?F I am the person responsible for the construction activities or this p. ojecc, for satisfying the
requirements of this permit, and for any civil or criminel penalties incur. ed due to violations of :his
permit.
The information submitted in this N01 is, to the best of my Icnowlddge and belief, true, accurate, and
complete based on my inquiry of the persor. or persons who manage the system, or those persons
directly responsible for gathering the information.
will abide by all conditions of the _i• .;J. J . and the approved Erosion and
Sediment Co,i-rol Plan.
If the approved Erosion and Sediment Control Plsn is not compliant with Part 11 (Stormwater Pollution
Prevention ,flan) of the ,"CCX-1 •" 7 C .r:.2. P,-. rod, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on'#'he project at all idmcs.
13 1 hereby request coverage uadcr the Cl--,'t'� .Fri. r : P��oni. and understand that coverage under
this permit will constitute the permit requirements for' -he discha.ge(s) and ;s enforeab!� in :he
same manner as an individual permit.
Name of Proiect: Southwick Solar, LLC
Legally Responsible Organizational Entity: Pine Gate Renewables, LLC
Legally Responsible Person: Chris Dunbar
Title of Legally Dft06Q Fe Son: Authorized Person
-Signature: j t/— ..r7l!!�
*Print Name and Title of Signed if Authorized
individual Differs from Permittee:
Phone Number:
Date: $1/ }1Zo Za
* 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 NCGO10000 permit.