NCC190339_NOI Signed Certification_20190521

NCGO1 Notic ication Form
Directions:
Print this form,complete,scan and upload to the electronic NO].
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy,Mineral&Land Resources Stormwater Program
S12 N.Salisbury Street,6 1h Floor
1612 Mail Service Center
Raleigh,NC 27699-1612
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 or a rule implementing this Article. ..shall be guilty of a Class 2 misdemeanor which may
include aline not to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all four boxes to indicate your agreement):
0 1 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.
n 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.
0 1 will abide by all conditions of the NCG010000 General Perm and the approved Erosion and
Sediment Control Pian.
11 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit I will nonetheless ensure that all conditions,of
Part 11 of the permit are met on the project at all times.
0 1 hereby request coverage under the NCGO10000 Ge nera1 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.
Legally Responsible Organizational Entity:_SDH Raleigh, LLC
JoelGeniesse, Registered Agent
Legally Responsible Person:
Signature: o-n Date:
*IMPORTANTNOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activit)�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 NCGO10000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCGO10000 Permit.