NCC192016_NOI Signed Certification_20190925

Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.6E (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 a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
FX1 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.
® 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.
® I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
IN 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.
LI I hereby request coverage under the NCGO10000 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:
Fort Bragg Federal Credit Union
Legally Responsible Organizational Entity: )._ tC:�., (� 'c. .� F- C) C-R
* Legally Responsible Person:
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Title of Legally Responsible Person: C,,O iC1= V-tP AC.tA,a-. FF-tc:EKzz.
Signature:
Date: el 9- ( r,,
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity, 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.

City of Fayetteville
433 Hay Street
Fayetteville, NC 28302
ToWhom it May Concern:
This letter serves as authorization for Jennifer King of DB Incorporated and/or Richard Lodhck of
RSL Commercial Architecture, on behalf of Ft. Bragg Federal Credit Union, to act as our
representative/agent in all building and planning requirements including but not limited to soil
erosion, storrnwater, etc. as it relates to our properties located at (New Branch) 1686 3kibo Road
(Parce|#D418-2]-0349)and (Branch Renovation) 1838SkiboRoad, Fayetteville, N[ 28303
Si
Carrie Rice
Chief Financial Officer
STATE OF
CuV,�[OUNTY
BEFORE ME, the undersigned authority, on this day per-sona|lyappeared known mme to be the person
who signed the above letter.
Given under myhand and seal ofoffice
On this —G date of f&. 2019
Notary bric)
91&9042232 FOR reuxooLncxTmws- rAYSTrsv/LLs LocArows:
*.lff'o(ft�ce. I jefiner Plaza, South rxoriv * 1638 Skibo Road, Fayetteville, mCz838
Bastogne Drive *a/oouummystreeLFayetteville, wcz8o|/
*m4onuutbrdRoad, Fayetteville, wCzo3o*
MAILING
1.800,7912328
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