NCC221361_NOI Signed Certification_20220425

NCGO1 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload tothe electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral Q Land ResourcexStormwater Program
51IN.Salisbury Street, 5,hFloor (Office 64OK)
2612 Mail Service Center
Raleigh, NC27699 1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification inany application, record, report, plan, orother docmnentfiledorrequired to6emaintained under this
Article ororule implementing this Article ... sho86eguilty o/oClass 2misdemeanor which may include ofine not to
exceed ten thousand dollars /$I0'UDD/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
F71 I 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.
[�| 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
gathering the information,
| will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
[�1 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit | will nonetheless ensure that all conditions ofPart Uofthe
permit are met onthe project atall times,
M | 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): Secrest CO0DrDoDs Tract 2
Specificb 1-75
Permittee(must match 8I): Forestar(USA) Real Estate Group INC'
Legally6| Robert Price
Title of Legally ResponsibleDirector ofReal Estate Investments &Development Carolinas
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Phone Number: [phone]
Sig -nature of Legally'Responsible Person or Authorized Individual
.;?- 7—
Date
*IMPOR0NTNOTE. This form must be signed byoresponsible corporate officer that owns moperates 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)o/the N[GO 0000pmmit.