NCC211735_NOI Signed Certification_20210325

NCG01 Notice of Intent {Nf31) Certification Form
Directions. -
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Storm titer 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 BEEACC
N REVIEWED AND EPTED AS COMPLET . E
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan,, or other document led 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 a fine not to
exceed ten thousand dollars ($10,000)..
Under penalty of law., I certify that (check all boxes to indicate your agreement):
sy 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.
The in -formation submitted in this NOI is, 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.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
I` the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the .N.CG01000_0 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
tol I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the j_-)ermit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Name of Project (must match Ala)., Arcadia Views SD - Second Entrance
Specific Lot NUmbers (must match Alb).- N/A
Legally Responsible Organizational Entity (must match Bi): WXZ/SG Acquisition, LLC
Legally Responsible Person (must match B2 & 83): James R. Wymer
Title of Legally Responsible Person (must match B3b): President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person: Mark G. Kopcienski, Senior Development Manager
440-476-9867
Pho�ne Number.
Signature of Legally ResponsiVe Person or Authorized Individual
Date
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 8,
Item f6) of the 11lCGO10000 permit.

I ITA 99 r*j Pj 4 UO
To: North Carolina Division of Energy, Mineral and Land Resources
Attn: Director
Re: WXZ/SG Acquisition, LLC
Permit No.: Vliws 5V,-'Seca 4d cat foots%ce
1, James R. Wymer, President of WXZ/SG Acquisition, LLC hereby authorize Mark G.
Kopcienski, Senior Development Manager, to sign, certify and file all applications, reports or
information required under the captioned permit.
I certify under penalty of law that this document and all attachments were prepared
under my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information submitted. Based on my inquiry of the
person or persons who manage the system, or those persons directly responsible for gathering
the information, the information submitted is, to the best of my knowledge and belief, true,
accurate, and complete. I am aware that there are significant penalties for submitting false
information, including the possibility of fine and imprisonment for knowing violations.
Sincerely,
James ymer, President