NCC205517_NOI Signed Certification_20201203

Print this form, complete, scan and upload to the electronic NOl.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at:
Division of Energy, Mineral & Land ResouoesStomovvater Program
512N.Salisbury Street, 6mFloor (Office 64OK)
1612Mail 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 Statute1���6B (i), any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article or a rule implementing this Article ... sholl be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars /$2(\000/.
Under penalty oflaw, |certify that (check all boxes to indicate your agreement):
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.
X1 The information submitted inthis NO|is, tothe best ofmyknowledge 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.
EK | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
N if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit | will nonetheless ensure that all conditions nf
Part Uofthe permit are met onthe project atall times.
EK | hereby request coverage under the 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.
NameofProiect: The Farm. at Neill's Creek
Legally Responsible Organizational Entity: Carolina Land LLC
Responsible Person: JiK3rbvLuFo/co
Title of Legally Responsible Person: Manager
*S
*Print Name and
eofSigned /fAuthorized
Individual Differs from Permittee:
Phone Number: 704-600-3085
*IMPORTANT NOTE: Thisformmust be signed by 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 B4Oem (6) of the NCGO10000 permit.