NCC212424_NOI Signed Certification_20210423

NCG01 Notice of Intent (N01) Certification Form
Print this form, complete, scan and upload to the electronic NC]i
Then, mail the original form tothe NC DEMLRStormwaterProgram (with $18Ocheck /fpmyingbycheck) at:
Division of Energy, Mineral & Land ResouncesStormvvater Program
512 N- Salisbury Street, 6m Floor (Office G4OK`
1Gl2Mail Service Center
Raleigh, NC27G99'16l2
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per @IGeneral Stotute143-215.GB(i),any person who knowingly makesonyfolse statement, representation, or
certificotimn/nany application, record, report, pbzo mrother docuo7entfiledurrequired tobenno/nto/nadunder this
Article cxorule implementing this Article. . . shall beguilty ofoClass 2misdemeanor which may include ofine not to
exceed ten thousand dollars /$1(l00CU.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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e� 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.
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The information submitted inthis M(}|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.
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| will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe Iwill nonetheless ensure that all conditions ofPart Uofthe
Ihereby request coverage under the NCG010000 General 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 (most match Ala): Southgate Business Park Lot 6
Legally Responsible Organizational Entity (must match B1): B.A.M. Properties of N.C., LLC
Name & Title ofSigned ifAuthorized Individual
Differs from Legaliv Responsible Person:
Phone Number: 919-661-14(a
im
Signature of Legally Responsible Person or Authorized individual
*IMPORTANTNOTE: This form must be signed byoresponsible corporate officer that owns moperates 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)ofthe NCGO 0000ponnit.