NCC192678_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20240429

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed,do NOT use this form.**
Instead,you must submit a new NCG01 electronic Notice of Intent(eNOI).
Directions:
Print this form,complete,scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.Salisbury Street, 6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage(COC) Number: NCC192678
Name of Project: Berkshire Lakemont-Pineville Distribution Street-Lot 1
Legally Responsible Organizational Entity: Intercon Building Corp.
PREVIOUS Legally Responsible Individual: David white
NEW Legally Responsible Individual: Michael Tulin!
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E(i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report,plan, or other document filed or required to be maintained
under 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).
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NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.221
Under penalty of law, I certify that (check all boxes to indicate your agreement):
® 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
permit.
0 I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit. I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
® 1 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.
0 This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: �� Date: 4/29/24
Print Name of Signed: Michael Tulini
Title: Project Manager
Mailing Address: 211 Atherton St.,Charlotte,NC 28203
Street Address: 211 Atherton St.,Charlotte,NC 28203
Email Address: [e-mail]
Phone Number: 847-975-6107
*IMPORTANT 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 NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.
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