NCC216660_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20230103

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCG01 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage (COC) Number: N LC Z ( AaLe (
Name of Project: �o o v\j oi)d 11 m Phocz 3
Legally Responsible Organizational Entity:
PREVIOUS Legally Responsible Individual:
NEW LeRalIV Responsible Individual:
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, 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).
Page 1 of 2

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Under 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.
I will abide by all conditions of the ,irr-ni nnnn r,Anarni Permit and the approved Erosion and
Sediment Control Plan.
l If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
I 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.
4 This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature:
Print Name of Signed:
t �
Title: �( \ S. )'
Mailing Address: ZQ -�'7c4
Street Address: j yp
Email Address:
As
H k 1D�J Q,v
Phone Number: I , — - a
Date: QQ3121529
* IMPORTANT NOTE: 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 B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.
is
Page 2of2

WAKE COUNTY FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Wake
County Unified Development Ordinance before this form and an acceptable erosion and
covi�T�t sedimentation control plan have been completed and approved by Wake County Department of
NORTH CAROLINA Environmental Services, Water Quality Division. (Please type or print and, if the question is not
-- �----- applicable, place N/A in the blank.)
Part A.
1. Project Name t ) eyxi.. ` L i S I -
2. Location of land -disturbing activity: Jurisdiction VYlI& ak (Wake Co. or Municipality)
Highway/Street a[(J jl Latitude i5 Longitude •14w
3. Approximate date land -disturbing activity will commence: O l ` 202- 2
4. Type of development (residential, commercial, industrial, institutional, etc.): rt.5 td
5. Total acreage disturbed or uncovered (including off -site utilities and borrow/waste
areas):_ _ I • �E nf"
6. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name 11ro•C , , E-mail3ail Address t ' 'r-Xv'iS � �
I ,�vi�n
Telephone Q A - Q'1- Q_.2 Cell # * - ACD- 21 U3 Fax #
7. Landowner(s) of Record (attach accompanied page to list additional owners):
}o
Name(s) Telephone
1'aos, cl'-LISnf 14 tu C'c V-d 5kdoi.
Current Mailing Address Current Street Address
-i r, � r `t CAL-.
City '' State
8. Deed Book No. Lo is
Part B.
Zip city
State
Fax or E-mail address
Zip
Page No. Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet. Include requested information):
Name E-mail Address
Ia. - . ; - 1.001
Current Mailing Address Current Street Address
City '' State Zip City
Telephone `f� �� Fax Number
State
Zip

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
State
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
7:1 �"
Ty e r print na Title or Authority
22
Signature U Date
a Notary Public of the County of 1
State of North Carolina, hereby certify that It(_-u l .�L appeared
personally before me this day and being duly sworn acknowledg d that the a-15ove form was executed by him.
Witness my hand and notarial seal, this day of �� 20�_
Notary
S al Janis Perez
NOTARY PUBLIC My commission expires
Johnston County
North Carolina
My Commisslon Expires August 4, 2026