NCC230837_NOI Signed Certification_20230329

NCGO1 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at
Division ofEnergy, Mineral & Land Resources 51ormxvaterProgram
612N.Salisbury Street, 6*Floor (Office G4OK)
1613Mail Service Center
Raleigh, 0C27699-1612
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 (NCI�IrDIGITAL) [40 CFk1 122.221,
Per NC General Statute 143-2156B(i), any person who knowingly mmkesmnyfalse statement, representation, or
certification inany application, record, report plan, orother dommentfiledorrequired tohomaintained under this
Article o/orule implementing this Article ... shall beguilty ufmClass 2misdemeanor which may include ofinenot to
exceed ten thousand dollars ($10,000).
Under penalty oflaw, | certify that (check all boxes tmindicate your agreement):
E�|amthe 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.
| will abide byall conditions ofthe and the approved Erosion and Sediment Control
56 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 ofPart Uofthe
permit are met onthe project a1all times.
| 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.
Name of Project (must match Ala): Apple Creek Corporation Park - Premix
Specific Lot Numbers (must match Alb):
Legally Responsible Organizational Entity (must match Bl): Premix Apple Creek Propedy. LLQ
Legally Responsible Person (must match B2 & B3): Jari-Matti Mehto
Title of Legally Responsible Person (must match B3b): pre,ai,nt & CFC)
Name 8'Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
ofLegally Responsible Person orAuthorized Individual
IMPORTANTNOTE. Thisform must besigned byuresponsible corporate officer that owns moperates the construction activity,
such asopresident, secretary, treasurer, mvice president, momanager that is authorized in accordance with Part IV, Section B,