NCC230843_NOI Signed Certification_20230329

NCG01 Notice of intent (NO9) Certification Forgo
Directions:
Print this form, complete, scan and upload to the electronic NCI.
Then, mail the original form tothe NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
51-2 N„ Salisbury Street, &I, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Dal NOT MAIL THIS FORM US OR PAYMENT
OMPLE ED WITH AN O IGINAL 5 GNATURE (NOT D COITAL) E40� R�122 221
THE F®RM 1'®U MAIL I�lIL15T 13E C
Per \IC v2nel"G'I �taiUte 143-215.6B 1i�, any person who knowirigly makes any false Sta[emcnt, representa ion, or
certification in any application, record, report, plan, a'- other docurlet filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a C1oss 2 misdemeanor which may include a fine not to
exceed 'ten thousand dollars (>10,000),
L t� ( i e� - l vases to indicate -our agrees!
Under penalty of law, ! certi�y that
ca': -..ai
i am the persoil I'eSpGn5lblE for the construction activities Gf this project, for satisfying the requirements o' .nis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
0 The i11fo1-mation submitted in this 'NGI is, to the hest of my knowledge anti belief, true, accurate, and complete:
baser? can my inquiry of the person or persons who rnanage the system, or those pa_rs.ons directly responsible For
gathering the information.
l, all
Th ap J ;nc n!� -n0I Ja i;jna r C0;-Lr0
\kill abide y' � , cOndUt%'.':5 Gt the NCGQ1(]Q00 General Permit and � c��;�-�-. - � --
Plan.
it the: approved Erosion and Sediment Control Plan is not compliant with Par` II (stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nsnethele:s er}sure that all vonditions of Part II of the
permit are rnet on the projerl at all times.
I hereby request coverage under the NCas010000 General Permit and u{iderstand that coo-2 rage ui,3ai this
perrnitwiII constitute the permit requirements For the discharge(s:) and is enforceable in the same rnanner as an
d..
iindividuall
Project Name (must match Ala): _f C.A-re_,D L a�
Specific Lot Numbers (must match Alb): a
ream -findcxs iAvmeS, LLLC.
Permittee (must match 81): �
Legally Responsible Person (must match B2 & B3): eslle Groves_ _---- —---
Title of Legally Responsible Person (must match B3b):
Dame & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Pho Number: 9'10-486-4864 -
-- - - .. -31131a3
_ _�--�--
Date
Signature of Legally esponsible Person or Authorized Individual
IMPORTANT NOTE: This form must be signed by a responsible corporote officer that owns or operates the construction activity,
such o,s a president, secretary, treasurer, or vice president, or o manager that is authorized in occordonce with Part IV, Section B,
Item (6) of the NCGO10000 peirnit.