NCC222758_NOI Signed Certification_20220816

NCG41 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 Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6t^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
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 .143-215.68 (i), any person who knowingly makes ony false statement, representation, or
certification in any apphration, record, report, pion, or other document filed 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 ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
Q 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.
❑✓ I will abide by all conditions of the NCGUIUDUO General Permit and the approved Erosion and Sediment Control
Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part it (Stormwater Pollution
Prevention Plan) of the NCG010DQ0 General Perm I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
✓l I hereby request coverage under the NC6010000 General Perrin 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): Myrtle Manor
Specific Lot Numbers (must match Alb): N/A
Permittee (must match 81); Gray Wolf Development, LLC
Legally Responsible Person (must match 82 & B3): Ben Mathis
Title of Legally Responsible Person (must match B3b). Chief Operating Officer
Name & Title of Signed if Authorized Individual NIA
Differs from Legally Responsible Person:
Phone Number: 91 9-934-7788
7/21 /22
Signature of Legally Responsible Person or Authorized Individual
Date
* IMPORTANT IVOTE: This form must be signed by a responsible corporate officer that awns or operates the construction activity,
such as a president, secretory, treasurer, a vice president, or a manager that is authorized in accordance with Part IV, Section 8,
Item (6) of the NCGO10000 permit.