NCC242137_NOI Signed Certification_20240716

NCGO1 Notice of Intent (NOI) Certification Form •
t s, Directions:
Print this fohrrt Complete, scan and upload to the electronic NOI. -••
Then, mail the original form to the NC DEMLR Stormwater Program (with.$120 check if payinciby'theck)
at:
Division of Energy, Mineral & Land Resources Stormwater Program 'f 41490. ''
512 N. Salisbury Street, Eoh Floor(Office 640K) . �f "
1612 Mail Service Center • •
Raleigh, NC 27699-1612
..
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT t1G1TAL);JA0£FR 122,2 —, ...r
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement, representation;or . • .? -•,-+a
certification in any application, record, report, plan, or other document filed or required.to be maintained under,.i i,, ,,.K. rN ,
.j11 .-
.4t-ticle or o rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor whictrmay include a fine n , ....,
exceed ten thousand dollors($10,000). r '-'
: r• 7
Under penalty of law, I certify that(check all boxes to indicate your agreement): ' •'.4. •
43 I am the person responsible for the construction activities of this project,for satisfyiirgtthe rekui,etispts, t tilis-
permit,and for any civil Or criminal penalties incurred due to violations:of this permit:
The information submitted in this NOI is,to the best of my knowledge and belief,true,accurate,and corrjplete-
based on my inquiry of the person or persons who manage the system,or thpse persQns,directly responsiblefor "
gathering the information.
E✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Contro!
Plan. i •_ :. ..:..•;.
4 •
E✓ 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 Part111 of the
permit are met on the project at all times. 41,
p✓ I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements•for the discharge(s)and is enforceable in the same•men4r as an �t.
individual permit. tl
Project Name(must match Ala)! Youngsville Animal Hospital "
Specific Lot Numbers(must match Alb):
Permittee (must match 81): MJBSquared Realty, LLC
Legally Responsible Person(must match 82& B3): Mike Bailey
Title of Legally Responsible Person (must match B3b): Manager
Print Name&Title of Signed if Authorized I
Individual Differs from Legally Responsible Person:
Phone Number: 919-610-8168 __
i -5( --7- a - ly
Signature of Le y Responsible erson or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president,secretory, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,Section 8,
Item(6)of the NCG010000 permit.