NCC201349_NOI Signed Certification_20200415

NCGo1 Notice of Intent (NO]) Certification Form
Directions -
Print this form, camplete, scan and upload to the electronic NQI.
Then, mail the original Form to the anti DEMLR Stormwater Program (with $1C0 check if paying by Cheek) at:
DMsinn of Energy, Mineral & Land Resources Sto,'mvrater Program
S12 N. Salisbury Street, G'' Floor (office 640K)
1612 Mail Service Center
Raleigh. NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
-- T REVIEWED AND ACCEPTED AS COMPLETE
Per MC Genera.1 Statute 143�2I5_63 (a any person who knowir,gly manes any false staternen r .represen,.M,cr,
or certlf icatit r in are application, record, repa ; purr, or other doL_urr ent filed .3r reguired .ra be mcxrn:cir�e�'
under this article arts ruler implementing this Article . _ . shafl be guity of a Cfass ? rnisdemearrar :v'hi.-h may
rnciude o fine n t to exceed tern thousand dDHars IS10,000).
Under penalty of :aye:, l certify all boxes to irsdicat? .Our agreement :
X € am the person respors:bie for the construction activities of thin for satisfying the
requirements of :1-i+ permit, and far any civil or criminal penalties incur-ed due to i'iolat cns. of thrs
permit_
the crforma#ion suLmitted in this NON �s, to the best of my knowledge and belief, True, accurate, and
comD.'-ete based on mq mgUirf of the person or person_-'aho TTianage The 5'j:iern, n- those personi
sire=: y respons:ble for gathering the zr:formatirn.
€ .,.€: a6:db by a!? conditio: �s of the NCCGICQQ Cenpral Permit and the approved Eros -on and
S}=d'rrtent Contra{ Flan_ -
X If The approved t-rasjor and Sedirnert Control Pia,, .s not compliant ti■rth Part 11 (Stcrn-.S,ater Pollutions
Prevention Rangy of the -'r ne, ' I wi:l r zmethele=ss ensure that811 c.vr?ditions of
Part I of the perrmt are met on the pro_ect at al: times.
X I `reraby represc coverage under the WGO.IC-?Hr 7 ,;1errmt and understand :hat cDverag,L under
this permit -vrl[ Constitute the permit •''equ.rerr.en�; fz�, _f]_? J:5chargeesi ar d is er[fcrreable rn the
same manger as an it dividua' permit.
Name of Proiect: Marsh Creek Self Storage
- ..._.... _.._ - e __. I-------.-•._----.- ---_
Lego€ly Responsible Or aniaatscsna{ Ersti ��ar5h Greek 3^vestments. LLC
- y .._�W ,,.
Legallally ryes ns�{ale f'er,:gn: .1Qf1�! E. Bradshaw III.n._�
Title of Legal1�,r Responsible Person: Manager
--signature-
'Print Dianne - j itle of Signed if-Autiiarir£d
!37 Pellalft3:
Phone Number. 910-232 2085
Date: ..., .1.. _
' IMPORTANTNOTE. Tih:s farm must we sig. cd by a resp•a; rsiafe COrparote officer that owns or aperQter the
ro ^struc:ion activit such as a president secretary treasurer, or trig presiders.*, or a m arroger that ds
cutharixed in GCCCrdGnce With Port IV. Sec -moan B. ftem (6) of the NC601011" permit.
For more inforrrmwion or s.�Jnurory requirements, see Part llr ,Section 6, Item f61 o the WG9i0r�'U perms-t