NCC232341_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20240711

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NCGOi1 Legally Responsible Individual Chan e F ran
III
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CH I NGE n the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, Jo 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 Permil MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Progr m at:
Division of Energy, Mineral& Land Resources Stormwater Prog am
512 N.Salisbury Street, 6" Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS F M F NTIL YOUR MODIFICATION HAS BEEN REVIEWED AND CCEP ED AS COMPLETE.
THE FO� M YOU MAI U BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT IGIT L) [�0 CFR 122.22]
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Certificate of Coverage (COC) Number: NCC232341
Name of Project: Edinborough
Legally Responsible Organizational Entity: DR Horton, Inc.
PREVIOUS Legally Responsible Individual: Tracey Davis
NEW Legally Responsible Individual: Neil Uldrick
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 stc tement, representation,
or certification in any application, record, report,plan, or other document filed or req iired 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 l all Responsible Individual Chan e Form
g Y p
THE FORM YOU MAIL U BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT E'iIGITA ) [ CFR 122.221
Under
/penalty of law, I certify that(check all boxes to indicate your agreement):
li` 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 iolations of this
permit.
L/ I will abide by all conditions of the NCGO10000 General Permit and the approved E losion and
Sediment Control Plan.
12' If the approved Erosion and Sediment Control Plan is not compliant with Pa II (St rmwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensur that all conditions of
Part II of the permit are met on the project at all times.
C I understand that coverage under this permit will constitute the permit requ remer is for the
discharge(s)and is enforceable in the same manner as an individual permit.
C This form has been reviewed and is accurate and complete to the best of mV know edge.
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*Signature: Date: D �y
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Print Name of Signed: Neil Uldrick
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Title: Division Stormwater Compliance Specialist III
Mailing Address: 4150 Mendenhall Oaks Parkway, High Point, NC 27265
Street Address: Same as above
Email Address: [e-mail]
Phone Number: 336-899-9240
*IMPORTANT NOTE: This form mustII be signed by a responsible corporate officer that c wns or operates the
construction activity,such as a president,secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part lV,Section B, Item (6)of the NCGO10000 permit.
For more information pn signatory equirements,see Part IV,Section B, Item (6)of thE NCG0 0000 permit.
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