NCC243067_NOI Signed Certification_20241004

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Then, mail the original form to the NC DEMLR Stormwater Program (with$100 check if paying by check)at:
Division of Energy Mineral R 1 anti Resources Stormwater Program
161? Mail Service Center
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B(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. .,stagg be gdfty. rf,a.77 '> .. .r_ s lt.74t' MC-7 iftCfU ie a f:TEf..Ci`
Under penalty of law, i certify that(check all boxes to indicate your agreement):
X1 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.
Xi The information submitted in this NOI is,to the best of my knowledge and belief,true,accurate,and complete
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
gathering the information.
Cg I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
l 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.
gl 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 manner as an
individual permit.
Name of Project(must match A1a): Taking Time-Phase II
Snerifir ..>',!easct rrrrtr{r' h): N/A
Legally Responsible Organizational Entity(must match.B1): Taking Time, LLC
Legally Responsible.Perssore tC. u5t ca tch 2& :. Jamie Q.Tatum
Title of Legally Responsible Person(must match B3b): Managing Member
Name C Title
of Sin it A 4tC5. .....i) .J .:....}.._I
Differs from Legally Responsible Person:
Phone Number: 910-371-2006
/0/V-2 c--1
Sig e of Legally Responsible Person or Authorized Individual Date
* T T k S b �.�.�. ...'l 1.
€A a NOTE; This rnn sr ite`�abyais i, 'rs�e:re rrc tetiffi 'hates s aperate3i cc s s y
such as a president,secretary,treasurer,or vice president,or a manager that is authorized in accordance with Part IV,Section B,
item(6j of the NC O1n000 permit