NCC201304_NOI Signed Certification_20200414

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the 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 Stormwater Program
512 N. Salisbury Street, 6"' Floor (Office 640K)
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 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 o fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
2"" 1 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.
0"" 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.
1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
IJ if the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
C� 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: F157 1cvAb i NVSo
Legally Responsible Organizational Entity: lj�r-_D-TOA-D 315 1Ji NJSon1
Legally Responsible Person:
Title of Legally Responsible Person:{3i
*Signature: Date: MAA. D
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: N1b - b6s-•
* 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 NCG010000 permit.

3127/2020
Resume Submission
Yy rw rrw Construction Stormwater: Notice of Intent
c ti.
r � }
(NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North
N Q R 1 I-4 CAR0LINA Carolina's General Permit NCGO10000: STORMWATER DISCHARGES associated with construction
EnWronmentaf Quality
activities (or NCG250000)
A. Project Information I B. Permittee Information I C. Site Contact information I D. E&SC Plan
E, Certification
Permittee Information - Legally Responsible Entity and Individual
Important: The person who signs the NO/ Certification Form and signs the Certification in Section E of this
application form should be the same person as listed in THIS SECTION, or an authorized responsible individual
within the same organization. That person must be a responsible corporate officer who 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 General Permit. For more information on
signatory requirements, see Part IV, Section B, Item (6) of that permit.
1. Organization Red Toad 315 Vinson Road LLC -
Name * If permittee is an individual (i.e., organization does not apply), enter first and last name in this field.
2.First Name*
Peter�����T��-�m_...-
If Corporation, enter Registered Agent First Name
3. Last Name*
Huges
If Corporation, enter Registered Agent Last Name
3b. Title*
FPresident
4. Permitee E-mail
[e-mail] _ _ ..,., ..__. _ ......._.
Address*
5. Permittee 1-416-605-2845
Telephone No.*
https//edocs,deq. nc,gov/Forms/form/resume/241 /54355 1 /2

31274020
Resume Submission
6. Permittee Mailing Street Address
Address63 The Kingsway
Address Line 2
City
Toronto
Postal - Zip Code
M8X 2T3
Check box if the Yes
street address the
same as mailing
address
7. Permittee Street Street Address
Address * 63 The Kingsway
Address Line 2
8, Type of
Ownership*
Previous
Save as Draft
City
Toronto
Postal / Zip Code
M8X 2T3
Individual
State / Province / Region
ON
Country
CA
State J Province / Region
ON
Country
CA
V
Next
M}ps /ledocs deq nc qov/Forms/form/resumel241/54355 2