NCC231065_NOI Signed Certification_20230417

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Storrwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Lind Resources Stormwater Program
512 N. Salisbury Street, 6,1, Floor (Office 64.0K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM ❑R PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.221
Per NC General Statute 143-215.5E(i), any person who knowingly makes ony false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained render 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).
Under penalty of lave, I certify that (cfEeti ail boxes to indicat-yowl aar earnei,'):
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 perrnit.
is,to the best of my knowledge and belief, true, accurate, and complete
The information submitted in this NOI persons who manage the system, or those persons directly responsible for
based on my inquiry of the person or
gathering the information.
r- �:'c n the approved Erosion and Sedirinent Control
vvill abide by al! conditions of the iVCfifl10Qd0 General Permit and �
Plan.
If the approved. Erosion and Sediment Control Plan is not compliant with Fart ii (Stor mw'ater Pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of Parl 11 of the
permit are met on the project at all times.
v, q i hereby request coverage- under the NCG0100>00 General Permit arid uncierstand thai c0'v i— ge ur!der'tl-ils
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same ! anner as an
individual permit.
Project Name (must match Ala):
Specific Lot Numbers (must match Alb): a 3
Permittee (must march 81):
ream fiY1dPXs #vtmes LLCG
Legally Responsible Person (must match B2 & B3):
eslie Groves
Title of Legally Responsible Person (must match B3b): �IVISIOn pYr;,Sld('X1�
Name &Title of Signed if Authorized Individual
Differs from Legally Responsible Person: -
Pho Number: 91 0-486-4864
31131 3 -
Signature of Legally esponsible Person or Authorized Individual Date
* 9MPOR 1 ANT 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 NCGO10000 permit_