NCC221959_NOI Signed Certification_20220525

Print this form, complete, scan and upload tothe 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 StormwaterProgram
512N. Salisbury Street, 6thFloor (Office 64OK\
1612Mail Service Center
Raleigh, NC 27699-1612
DONOT 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 122.22]
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, or other documentfiled 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 ($1(lDD0}.
Under penalty oflaw, | certify that (check all boxes toindicate your :
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.
[�l 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 NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
F-/ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permjt | will nonetheless ensure that all conditions ofPart ||ofthe
permit are met onthe project atall times.
[.71 | 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): MTX[]Oe
[Ot1���14
Specificbe
Permittee (must match Bl): STALBANS H[][[lINGS[hC
Thomas ��aieSdJr.
LegallyResponsible
Title
of Legally Responsible Person (must match B3b): Manager
Name & Title ofSigned ifAuthorized Individual
Differs from UResponsible
Phone Number: 9192398233
—�- Z
*IMPORTANTN��This form must be signed byoresponsible corporate officer that owns oroperates the construction activity,
such osopresident, secretary, treasurer, orvice president, nromanager that isauthorized /naccordance with Part IV, Section 8,
Item (6)oƒthe N[602D000permit.