NCC201398_NOI Signed Certification_20200413

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 ofEnergy, Mineral & Land Resources StormwmterProgram
512N.Salisbury Street, 6mFloor (Office 64OK)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NZGeneral Statute 143-215.68(i), any person who knowingly makes anyfalsestatement,
orcertification /nany application,record, report, plan, orother dvcument/Uedor required tnbemaintained
under this Article, or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars ($2[\[D)D).
Underpenahvof law, | certify that (check all boxes toindicate your agreemen8:
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 inthis NO|is, tothe best ofnmyknowledge 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.
| will abide all conditions nfthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
�� ' | with U Pollution
�= �theaporovedErosionand�edimant Plan isnntoonmp�ant � �tonnvvater
Prevention Plan) ofthe NCGO10000 General Permit | will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project otall times.
5� | 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 of Proiect: McConnell Commercial IK8(][3and Convenience Store
Legally Responsible Organizational Shix Sumangala, LLC
Legally Responsible Person: Balvantbhai Patel
Title of Legally Responsible Person: K8 ber/Shiv Sumangala, LUC
*Print Name and Tile of Signed if Authorized N/ck-61 �1 0'-1 10 ajve4
Individual Differs from Permittee: err-'&el�
Phone Number: 704-737-1555
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, orvice president, oromanager that is
authorized /nmccondoncewith Part IV, Section £LItem (6)ofthe N[GD2O0OOpermit.
For more information ons/gnoboryre4uiremnents, see Part IV, Section f,Item (6)4ƒthe NCGO2OUOOpermit.