NCC223202_NOI Signed Certification_20220913

NCGO1 Notice of Intent (NOU) Certification Form
Directions:
Print this form, complete, scan and upload tothe electronic NO|.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StonnwmtorProgram
512N.Salisbury Street, 8*Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC27689-1G12
DO NOT MAIL THIS FORM OR PAYMENT 0NT�LYOUR APPLK�J0�������������pTED AS COMPLETE.
THE �MAIL MUST BE
FORM YOU ^'-- COMPLETED~^ - ORIGINAL SIGNATURE (NOT DIGITAL) [40
-~--~`-''R '
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 ororule implementingthbArdde...sho8beouiltvofoCYoxn3nnisdenreonorwhich/noy/ndudeo8nenot to
exceed ten thousand dollars ($10,000).
Under penalty oflaw, | certify that (check all boxes bmindicate your :
Fv� I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil orcriminal penalties incurred due toviolations of this permit.
The information submitted in this NO| is, 1othe best ofmy 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.
c� | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
FvJ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions nfPart Uofthe
permit are met on the project at all times.
[3 | 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): NC-1 1 Self Storage and Flex Office
Specific Lot Numbers
Pennittee(must match 81\: Dp[]Properties I I L[C
Legally Responsible Person (must match B2 & B3): Derek[lQnO
Title of Legally Responsible Person (must match B3b): Manager
Name 8'Title ofSigned JAuthorized Individual
Differs from Legally Responsible Person:
[phone]
Signature kf Leg�lly Responsible Person or Authorized Individual
*IMPORTANTNOTE. This form must be signed byuresponsible corporate officer that owns moperates the construction activity,
such osopresident, secretaM treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,