NCC222156_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20240709

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(eN01).
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: \C)C,2 p' 151.Q
Name of Project: V RQ` ( z \-txv _--cpU)rsJ/
Legally Responsible Organizational Entity: T T . 'ran 1 r •
PREVIOUS Legally Responsible Individual: C}elS--)1Drhd hVers
NEW Legally Responsible Individual: oRf--- ‘C M e,r
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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NCGO1 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Under,enalty 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.
/
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
/I
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.
/
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.
2/
This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: A.Ar1 .iC .. •
, Date: C71611 `-f
Print Name of Signed: V Q,%)ak ,Q,tte1
Title: rY1V1/ C ✓ 1 i SPA e CLQ 1 4- c,
Mailing Address: 1 1 Ca- C- P/<wck,t ( ) Si*u I WA[ I"1, .Svi 6kNC.ar tot
Street Address: .SCLAne. CIS cJ7ov\e,
Email Address: jaYYleiA-eC cvhari-on . LOv'
Phone Number: Q),q. 2,15 . u5l.Pt
* 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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