NCC210767_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20240613

NCGO1 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
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.
1 will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
/Sediment Control Plan.
El if the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
I2/ I 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.
l✓J This form has been reviewed and is accurate and complete to the best of my knowledge.
*Sig natur . Date: 5 1 '4i/
Print Name of Signed: I .fl t� lb ram.
Title: i 1'Q r O"C i-(2tA t� 01-0,40pra.i.AJ
Mailing Address: 1 Q 3 a5 �� � c ItA9 / 5
Street Address: ( 1Gt.r!() c)1'
Email Address: • 1 Jo e ii Pole he n'us . ex m
Phone Number: '? / 7 /3- / / 73
* 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 8, 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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NCGO1 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 NCGO1 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(COG) Number: ` �e; 1 v 7107
Name of Project: Du0i'l.S et-,1 &-n..ei_an f��
Legally Responsible Organizational Entity: sal Pau-11-s 1-4 ery-a ?S 4 wiu-d'gO
Talc
PREVIOUS Legally Responsible Individual: LLk . LA)00dle)LA--r f _
NEW Legally Responsible Individual: &... ` LO
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.68(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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