NCC230600_NOT Signed Certification_20240402

NCGO1 Notice of Intent (NOU) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N0L
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land ResuurcesStormwater Program
512N. Salisbury Street, 6~ Floor(Office 64OK)
161Z Mail Service Center
Raleigh, NC27699 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^(NOT DIGITAL) [4OCpR 122.22]
Per NC General Statute 143-215.6B(i), any person who knowingly makes onyfalse statement, representation, or
certification in any application, record, report, plan, or other dncunnentfi/edor required to bennu/nto/ned under this
Article or o rule implementing this Article. . . shall be guilty of (Joss 2 misdemeanor which may include u fine not to
exceed ten thousand dollars ($2(l000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
[7l \ am the person responsible for the construction activities of this project,forsatisfvingtherequi/enoentsnfthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
[/l The infnrnnadonsubnoitted }n this ND) is,to the best ofmyknovv>edQe and be)}ettrue, accurate, and complete
-- based or) my inquiry of the person or persons who manage the systern, or those persons directly responsible for
gathering the information.
| will abide by all conditions of the N[GO10000 General Permit and the approved Erosion and Sediment Control
Plan.
[7l (ftheap�roved [rodonundSedinnentContnx| P\anbnutcnnnp|iantvvithPa/t |\ (StnrnnwaterPoUutinn
f 000 General Permit, i will nonetheless that all condihonsofPart || of the
PreventionP>an) o the onera er/� , vv none ee�sen�ure
permit are met on the project at all times.
��l | hereby request coverage under the N[G010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable in the sarne manner as an
individual permit.
Project Name (must match A1o):Eagle Point Golf Club p8[ 3 Renovation
Specific Lot Numbers(must match A2b): N/A
Permittne (must match 81): Eagle Point Golf Club, Inc.
Legally Responsible Person (must match 83& 83): Robert Long, jr.
Title of Legally Responsible Person (must match 83b): President
Name &Title of Signed if Authorized Individual
N/A
Differs from Legally Responsible Person:
�
Phone Numbec10-686-4653
Signature of Legally Responsible Person nrAuthorized Individual Date
* /0xP7RT4NTIVOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such oso president,secretary, treasurer, or vice president, oro manager that is authorized/n accordance with Port IV,Section f,
Item/6Yof the N[GO20000permit.