NCC192835_Contact Update (LEG RESP CHANGE)_20210406

NCGO1 Legally Responsible Individual Change Form
Undeer/penalty of law, I certify that (check all boxes to indicate your agreement):
L� I am the person responsible forthe 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.
L� I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan,
I/ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
S I 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.
lie This form has been reviewed and is accurate and complete to the best of my knowledge.
�� Date: YAPnI 5 I aOo2i
Print Name of Si
/^� J
Title: 1-
Mailing Address: 1 40[) ti-ic 2oQy �l(� all c — F?uQ 6 C , [ U )QC 2 t9SW
Street Address: Acne. (tS A%pUQ
Email Address: -t— (G��p�.ery)a(\ V i` � • kLl,rn • ()Gk uS
Phone Number:
* 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.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCG010000 permit.
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