NCC204087_NOI Signed Certification_20200922

NCG01 Notice of Intent (N01) Certification Fora
Directions:
Print this form, complete, scan and upload to the electronic NQI-
Theo, (nail the original farm to the NC DEM LR Storrnwater Program {with 5100 check rf paying by check} at;
Division of Energy, Mineral & Land Resources Sto rrnwater Program
512 N. Salisbury Street, 6T' Floor (office 640K)
1612 Mail Service Center
Ralei8h, NC 27699-1612
DO NOT EMAIL THIS FORM OR PAY iMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215- 68 (i), uny person wh o kn owingly m okes any fosse s to remen t, represen tabor,
or certrficotlon in any uppllcatlon, record, report, plop, or other document filed or required to be mvintained
an der this ,article or a rule lrnplernenting this Article - - , shrill be Wlry of o Ooss 2 rnlstlemetmor which rimy
include a fine not to exceed tern rhousar;d dollars ($10, 0)-
Under penalty of law, I certify that (check all boxes to indicate your agreement);
W7 I am the person responsi ble for the ccnstruction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
perrnit-
KI The information submitted in t#n is 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, ar 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,
M If the approved Erosion and 5edirnent Control Plan is not compliant with Pa rt 11 (Storm ateT PQIlution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit afe met on the project at all times-
1 I hereby request coverage under the NCG010000 Genera l_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- Freedorn Drive MOB
Legally Responsible Organizational Entity+=_ Freedom opportunity Fund, LLC
Legally Respon.5ible Person: Via; ki .F. r- tiles 4 1f C I
Title of regally Responsible Person; Manager
*Signature date, { zo D
*Print Name and i e of Signe Aunccri,zed
individual Differs from Pefmfttee-
Phone Number; 4 • (PIZ-
* 1AVORTANT NOTE. This form racist be signed by a responsible corporate officer that Owns or operates the
cons rruction activity, such as o president, secretory, treasurer, or vice presfdent, or a monaper that is
authorized in accordonce with Part IV, Seaiun 8, Item (6) of the JVCG010000 permit -
For more information on signatory requirements, see Part 11! Section 8, tter n (6) of the IVCGOI0000 permit.