NCC204612_NOI Signed Certification_20201020

NCGO1 Notice of intent (NQI) Certification Form
I IG 1 -,I.- 1.
Print this form, complete, sin and upload to the 6ectronic NOC
1 Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) It. -
Division of Energy, Mineral & Land Resources Stormwatw Program
512 N. SoNribury Street, 6°i Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THUS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General5tatutc 143-215.66 jif, any person who knowingly makes anyfoist stotemen► reraresenjotiun,
ur esrtificution in any application, record, report, plan, or other document fled or required to be maintained
under this Article or o rule impkementing this Article ... shall be guilty of o doss I rriisdemeumm which may
include a firne riot to exceed ten thousand dollars ($I0,000).
Wider penalty of law. I certify that (check all boxes to indicate your agreefrein*
.1�1 am the person responsail* for the construction activities of this project, for satisfying the
reourremm,-% of this permit- and for arty civil or c6minal penalties incurred due to violations of this
permit
The information submitted in this H01 is, toest the bpf my l rtipwic-0r and briief, vuf, accurate, and
complete based on my inquiry of the pe'm4 n or peryorn who rnanage the system, or those persons
erectly responsible for gathering the,nfprrnbipm
I will abode rN all mnditiom of the NCG4?1M General Permit and the approved lrcnion.)rid
5�-dirrK:nt ContrN Plan-
ff &* approved Erasion and 5c-dwncnt Con"I Plan 6 not cDrnpiiant with Part 11 (Stormri►atpr Pollution
Prevention Man) of the N-CGCIDX)C` +-�-rrip rai l'z ern I wi11 norset)el,m. Pniure thlt it [.rendition} of
Part p of the permit are met on the wo*i at all times.
f hereby request cawwave under the 4CG010Q,,1L'' Lrf fz r 'e Pt•r r- and understand tt+at coverage under
this permit will aanstime the permit mcli cements for the discharge(s) and is entorceabSe in the
same manner as an individual permit.
Name of Project: BRICRTON DR DEVELOPMENT
Legally Responsible Organiiatwnal Entity: BRICKTON REALTY PARTNERS, IMF
Legally Responsible Person; DENN I S G . GOODWIN
Title of Le - I Res n - Is P n_ OI�TNE
..o
" Signature: - Date:
*Print Name aitlp4f5igned if Aut tied
Individual (Nffersl0m Permitter- 'Cy AI t iXe l
Phone Number. 717-578-34 5
' IMPORTANT NOTE: Thisform must be signed by a rrspormisle corporate pf er that awns of operates the
currstructio,n octivity, such as a president: secretary, treasurer, or vice president; or o manager that its
authorized in accordance with Part IV, Section B, Item (6) of the NCM100W per►mt.
For more inforrnoGan err srynotory requirements, see Port IV, Section B, Item (6) of the NCG010000 permit,