HomeMy WebLinkAboutNCC192116_NOI Signed Certification_20191001Fill III!
Ohen, mail the ori,,ri
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLE'T1
Per NC General Statute 143-215.68 (1), 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):
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, NO[ 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.
N1 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.
I hereby request coverage under the,!iCGO10000 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: Banner Elk Mini Storage Development
Legally Responsible Organizational Entity: Banner Elk Mini Storage, LLC.
Legally Responsible Person: Ethan Anderson
Title of Legally Responsible Bwson: President
*Print Name and Title of Signed if Authorized
Individual Dffers from Permittee:
Phone Number: (828) 265-9812
*IMPORTANTMOTE; This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as 0 president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV
I , Section B, Item (6) of the NCG01 0000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO1000o permit