NCC241534_NOI Signed Certification_20240520

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this orm, complete,scan and upload to the electronic NOI.
Then, mail the original form uo the NC DEMLR Stormwater Program (with $120 check if paying by check)
at:
Division of Energy, Mineral & Land Resources Stormwater Program
.12 N. Salisbury Street, 6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE OMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.68(i) any person who knowingly makes any false statement, representation, or
certification in any application, recor. report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Art cle. . . shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000 .
Under penalty of law, I certify that(ch-ck all boxes to indicate your agreement):
Q✓ I am the person responsible f.r the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or cri final penalties incurred due to violations of this permit.
0✓ The information submitted in his NOI is,to the best of my knowledge and belief,true, accurate, and complete
based on my inquiry of the pe son or persons who manage the system, or those persons directly responsible for
gathering the information.
0✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
Q✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG01,000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project :t all times.
E✓ I hereby request coverage and-r the NCG010000 General Permit and understand that coverage under this
permit will constitute the per it requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): K du Properties
Specific Lot Numbers (must match A1b):
Permittee (must match 81): Kudu roperties
Legally Responsible Person (must m.tch 82& 83): Ryan Jackson
Title of Legally Responsible Person ( ust match 83b): Owner
Print Name &Title of Signed if Authorized
Individual Differs from Legally Responsib Person:
Phone N r 919 1 --- " 6
5/16/24
':►.rture Legally Responsible Person or Authorized Individual Date
* IMPORTANT NOTE: This form must be si!ned by a responsible corporate officer that owns or operates the construction activity,
such as a president,secretary, treasurer, .r vice president, or a manager that is authorized in accordance with Part IV,Section B,
Item (6)of the NCG010000 permit.