NCC192642_NOI Signed Certification_20191104

NCGO1 Notice of Intent (NOU) Certification Form
Print this form, complete, scan and upload tothe electronic NOi
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 Sturnxwater9roBram
512N.Salisbury Street, 6mFloor (Office 64OK
1612 Mail Service Center
Raleigh NC27G991G12
DO nOT
REVIEWED AND ACCEPTED AS COMPLETE
Per N[General Statute 143-215.6@(i),any person who knowingly makes anyfalsestatement,
or certification/nonyopp&cotion,recund,nepmrt,p6an,orotherdocumenttUednrnequiredtobemnm/nbzined
under this Article ororule implementing this Article ... shall beguilty ofmClass 2misdemeanor which may
include ofine not toexceed ten thousand dollars ($2(lUL0).
Under penalty of law, |certify that (check all boxes toindicate your :
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.
a�^ | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit, | will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project otall times.
mu | 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 asanindividual permit.
Name ofPnoiect: South Point Commons - Phase I
Legally Responsible Organizational Entity: SP Village LLC
LegallyMacon
Title of LegaIIyAesponsib1tygx&Gg,:--, Development Manager
*Print Name and Title of Signed if Authorized
Phone Number: 704-56/-5308
*IMPORTANTAOTE/This form must besigned hyo responsible corporate officer that owns oroperates the
construction activity, such oso president,xcoetory, treasurer, orvice president, oromanager 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.