SWA000053_Corrected Pages of Stormwater Fast Track Application_6/4/2019

The Applicant, who isalso the Financially Responsible Pmrty, identified inSection Oofthis form must sign and have
notarized the following guaranty:
(print ortype name of ApplicantlFinanciallyReaponoible
certify that the information included on this permit application form is, to the best of my knowlec4e, corred and/
that
1. the design has been or will be completed in accordance with the MDC as set forth in Rules 15A NCAC
D2H.1O5Othrough .1O82.tothe best ofmyknowledge;
2. the completed design meets or will meet the IVIDC and that the percentage BUA that is the basis for the
design shall not beexceeded, tothe best ofmyknowledge; and
3. As the applicant, I shall maintain a licensed professional of record for the duration of the project
who will prepare and certify the as -built package. U|retain another licensed
professional before the project ionomop|ate'then|ehaUprmvideanupdmted
guaranty with the current licensed professional's seal. Alicensed professional shall inform
the Division if he is no longer associated with this project.
The above information istrue and correct tothe best of my knowledge and belief and was provided bymaunder oath
agree toprovide corrected information should there beany change in the information
Type orprint name Title orAuthority
I, '30-5c,�O�N�e, 9 SC_kA,_,X­_VA a Notary Public for the State of county
ofo C& do hereby certify that personally
and acknowledge the due execution of
the application for a stormwater permit. Witness myhand and official seal.
S U S A =tNB
TjkRy PUBLIC
[cabarrus COuntY, �,Iorth caroona
ro I iresL_
Stormwater Fast Track ATC Application Form Page 8 of 11 Feb10,2018

|' (print ortype name nfthe
own thejroperty dentified in this permit application, and thus give permissi6n to (pfint of type name of Applicant)
C-3a-�' �'B'weem with (print or type name of Applicant's
organization) :B4vco,",-v to develop the project as
currently proposed. A copy of the lease(agreemer(t or l5ending property sales contract has been provided with the
submittal, which indicates the party responsible for the operation and maintenance of the stormwater system.
As the legal | acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DEMLR Stormwater permit reverts back
to me, the /s the ummyresponsibility a
completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater treatment
facility without a valid permit. I understand that the operation of a stormwater treatment facility without a valid
permit is a violation of NC General Statue 143-215.1 and may result in appropriate enforcement action including
the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature: Date:
1, a Notary Public for the State of CnLk-Z)�t C�-- , County
Of doherebvcertify that personally
appeared before methis dayof Sc-5r-p�� and acknowledge the due execution of
the application for a stormwater permit. Witness my hand and official seal,
My commission expires i- 'iL
NOTARY PUBLIC
Cabarrus County, North Carolina
LMy Commission Exores_____�
Stormwater Fast Track ATC Application Form Page 10 of I I Feb.10,2018