NCC224054_NOI Signed Certification_20221220

CG01 Notice of intent (NO1) Certification Form
Directions:
Print this form, complete, Scan and upload to the electronic N0I,
Then, mail the origi nal form to the NC DEMLR Stormwater Program (with 100 check if paying by check) at:
Division of Energy, MineraI & Land Resources Stormwater Program
512 N. 5alisbury Street, 6:h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THl5 FO RM OR PAYMENT UNTIE YOUR APPLI AT10N HAS a�EN ACCEPTED AS COMPLETE.
THE flQ__W YOU MAIL MUST BE COMPLETED WITH AN 0REGINAL SiGNATURJE (NOT DIGITAQ [40 CFR 122,221
Per NC General Stotute 143-21S.68 tij, any person who knowirrgf}r makes c7ny false statemet)r, representation, or
certification in any opplication, record, report, plan, or o ther document feed or require' to be mointoined under this
Article or a rule irnplemt ruing this Article _ , . shall be guilty of (7 Class 2 mrsderracan or which may irrtfude ❑ fir)e riot to
exceed ten thousand dollurs ( 10 000).
Under penalty of law, I certify that (check ail boxes to indicate your agreement):
Q I am the person responsible for the construction artivities of this project, for satisfying the requirements of this
permit, and for any Civil or crimiria I penalties incurred due to violations of this permit_
El The information submitted in this NOI A,, to the best of my knowledge and belief, true, accurate, and complete
Lased on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information,
21 l will ab[de by ail conditions of the Q01i)000 General permit and the approved Erosion and -Sediment Control
Plan.
❑✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (5tormwater pcifurion
Prevention Plan) of the IkiCGC} i!(}p0_Gerrer l permit, I will nonetheless ensure that all condition,S of Part II of the
permit are met on the project at all times.
[✓ I thereby request coverage under the NCG010W0 General Permit and understand that coverage under this
Permit will constitute the permft requirements for the discharges} and is enforceablle in the same manner as an
individual permit_
Project Narne (must march Al a): H ighway 52 Convenience Store
Specific dot N u m bers (must match AIb): /A
Permittee (mast match 81): 1 elcome rtL
Legally Responsible Person (rnu t moteh 52 & 63): bevindra Patel
Title of Legally Respcin5i ble Person (must match 83b): Managing Member
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person; NIA
Phone Number: 72-504-9 63
Signature of Legally Responsible Person or Authorized Individual Date
I PORTANTNOTE. This form must be signed by a responsible Corporate officer that awns or aPerates the construction octivity,
such os a president, secretary, tleQsarer, Or vice- presiden t, or a manager that is authorized in accardonce with Port IV, Section a,
item (6) of the NCDI0000 perrnit.