NCC191551_NOI Signed Certification_20190828

NCGOI Notice Ind I i i ili m.
IPrurut this fours, complete, scars and upload to the electronic NOS,
Then, maul the original fora to the NC DEMLR Stanrrr water Program (with $100 check if paying by check) at:
Division of Energy, I nraeral & Land Resources Stormwater Program
2 N., Salisbury .Street, 6 rh Floor
1612 Mail .Service Center
Raleigh, NC 27 g-1612
Per NC General Statute 1 3- .1 . (a), any person who knowingly makes aruy.fa lse .statement, representation,
or certification in any application, record, report, plan, or other document filed or required red to be maintained
fined
sander this Article or da male implementing this Article .. , shall be guilty of as Class 2 misdemeanor r which may
include aftne not to exceed ten thousand drillers ($10,0 ).
Under penalty of lamp, l certify that (check all boxes to indicate your agreement):
II am the person responsible for the construction activities of this project, for satkfying the
requirements of this perrrmut, and for any cuaru0 or crurrmkia0 penalties incurred dune to vuarlatuoru.s of this
permit,
3° The Information submitted in this NOI is, to the best of my knowIed e and befief, true, accurate, and
camrnplete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gatherIng the information.
„ l mallll abide by all conditions of the 10 and the approved pu,.osuon auud
Sediment Co ntrda III°llauno
It the iq�,:iuproved Eui,nsuon and Sediment Control Plan its not conn,pluant vvr th Part Il (t`rarm wat a t''OHu,.ot*n
Prerert: on Plain) of the
, l mn & non,,,thdess ensure that alH c:rrn6tJurns of
Part ll of the perrnr t are met on the project at all turmnes
I hereby request coverage under the grad understand that csvetap7e uuurpe�r'
permit
this pert well cuw�nstdtu�te the peri..Jt requs reronecnt.s for the &scharge(s) and us eiiff :,u c eathe� In rliae
Same manner as au°u Individual perrmt,
Name of Project- � M a� o _ \J c
Legally Responsible Or ainuzadonal Entity: n �a � 4� ." u"' � �u.,t'"��m � u C LLC_
Legally Responsible Person: �1, � �r
Title of Legally lResponslhl ers n: _�V 1 1 0�
WM
IMPORTIMPORTANt NOTE. Thisform must be signed by a responsible corporate officer that owns or operates the
a onstru c6on activity, such as as president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with wart IV, .Section B, Items (6) of the NCGO.10000 permit,
For more ipformation on signatory requirements, see part IV, .Section g, items () pf the NCGO10000 permit.