NCC222274_NOI Signed Certification_20220622

NCG01 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 5tormwater Program (with $100 check rf paying by check) at:
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salisbury Street, 6,, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
❑O 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 122.2Z]
,NC Gen eral Statu te 143-215.611 (i), any person who knowingly makes any false stotern err t, representation, or
tification in any application, record report, plan, or other document filed or required to be maintained under this
isle or a rule implementing this Article ... shall be guilty of a Class 2 misderneanor which may include a fine not to
geed ten thousond dollars ($10,000).
der penalty of law, I certify that (check all boxes to indicate your agreement):
✓�] 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, a nd 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 NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
[✓ If the approved Erasion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that afl conditions of Part 11 of the
permit are met on the project at all times.
Q I 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): McLean Landing Subdivision
Specific Lot Numbers (must match Alb);
Permittee (must match 01): BC Prime, Inc
Legally Responsible Person {must match 82 & B3): ScottClark
Title of Legally Responsible Person (must match 133b): Vice President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-244-1001
of Legally nsible Person or Authorized Individual 7Port)
tMPBRTANT IYDTE: This form must be signed by a responsible corporate officer that owns or operates the etivity,
such as a president, secretary, treasurer, or vice president or a moaager that is authorized in accordance wition 8,
item 16) of the NCG010000 permit.