NCC222796_NOI Signed Certification_20220812

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Starmwater Program (with 100 check ff paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 60, Floor (Office 640 )
1612 Mail Service Center
Raleigh, NC 27699-1.6-12
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 1 .3- 15. B (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or require d to be rrraintoined under this
Article or a rule implementing this article ... shaft be guilty of a Closs 2 rr isdemeanor wh ich may include a fine not to
exceed tern thousand dollars (. 10,000).
Under penalty of law, I certify that (check all bakes to indicate your agreement):
❑� I am the person responsible for the construction activities of this project, for.satisfying the re uirements 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.
I will abide by all conditions of the NCG010000 General Permit and the approved Frosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part It (tormwater Pollution
Preventjon Plan) of the iV CG 010000 Gene_ra!_ Permit, I wiII nonetheless ensure that all conditions of Part II 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 sarne manner as an
individual permit.
Project Name (must match Ala): Furrst Class Cars
Specific Lot Numbers (must match Alb): n/
Permittee (must match Bj): Furr Holdings, LL .
Legally Responsible person (must match 82 & B ): Brandon Furr
Title of LegaIIy Responsible Person (must match 3b): Ma n ag in g M ember
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number:
=1002
Signatu a of le l Peon ible Perj on or Authorized Individual
zlzz
Date
1A4P RTA1VTN0TE: 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 8,
!tern (6) of the NC O10000 permit.