NCC233313_NOI Signed Certification_20231107

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airec'siZ ns:
Print this Form,complete.scan and upload to he electronic t'tiLi.
Then,mail the original torm to the tit_ i 1Fitli►t Stormta' ter Program (with r 1 7P.rherk rf po m y by rheck)
at:
Division a Energy,Kiwi al&Lain Resiiurces rii3iCiiiirfi[ci iiacgiaiii
S,2 .) Salisbury St.--_.. a...re.:.::Iriffic.:;Pn1t'
Sc-w N. .31�.1.aai..,y .Jk.i'i:•.. �. Floor tv1.1i._ v-.v
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1V 1L 1VI011 JGi VIC.G\.GIICCI
Raleigh. NC 27699-1612
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement. representation,or
certification in any application, record, report,pion,of other doLilniellt l./c C1 of re.tri U; Cu tv uL rl rul1 ll i.V;$ 1,u e0 IA,. ...,.,
Article o li rule implementing this Article. _hall be guilty if-Class 2 misdemeanor}31 fitr may include _:
eAceed ten thousand dollars ($10,000).
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ID 1 am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
ne ;n;or nation suero ttce,, to tots Nut is,to Inc acst or my Know;cogc ono ;.c:,c,,m,uc,accu:a.c,ano corrpic:c
ilG�:11 Ull)Jl/ Li L11C);.iei m of pe)SLI))a wl)u lnollaise 11)C?yslrll), Ul 1I)L t Ott') 'L') U1!elil)y)e.�1,lL1!)S)L,$t'kJ/
gathering the information.
r.1�:de by all Condition_ `f thn C.-nn
❑✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Star rnwater Pollution.
Prevention Plan)of the NCG010000 General Permit.!will nonetheless ensure that all conditions of Part II of the
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[✓ (hereby request coverage under the NCGOI0000 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
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Project Name(must match Ala): Beroth Circle
Specific Lot Numbers(must match Alb):
Permittee (must match 81): Beroth Circle. LLC
Legally Responsible Person(must match 82& 83): VIC Beroth
Title of i_egatty Responsible Person(must match 83b): Manager
Print Name&Title of Signed if Authorized
individual Differs from Legally Responsible Person:
Phone Number: [phone]
Signature of Legally Responsible Person or Authorized Individual Dale
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity.
such as o president,secretory, treasurer,or vice president, or a manager that is authorized in accordance with Part IV,Section 8,
Item(6)of the NCGO10000 permit.