The URL can be used to link to this page

Home My WebLink AboutNCC212705_NOI Signed Certification_20210505DocuSign Envelope ID: D54AC7A5-2375-454B-A59B-D993AE3054E1 NCG01 Notice of Intent (NOI) Certification Form Directions: Print this form, complete, scan and upload to the electronic NOI. Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at: Division of Energy, Mineral & Land Resources Stormwater Program 512 N. Salisbury Street, 6,1 Floor (Office 640K) 1612 Mail 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 Statute 143-215.6E (i), any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed 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): V 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 information submitted in this NOI 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, or 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. If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the permit are met on the project at all times. IV I hereby 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 Proiect (must match Ala): Chick-fil-A Specific Lot Numbers (must match Alb): N/A Ily Responsible Organizational Entity (must match Bl): Chick-fil-A, Inc. Legally Responsible Person (must match B2 & B3): John Mark Wood Title of Legally Responsible Person (must match B3b): Director Name & Title of Signed if Authorized Individual Differs from Legally Responsible Person: N/A Phone Number: 404-765-8000 4/29/2021 1 7:55 PM EDT Signature of Legally Responsible 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 B, Item (6) of the NCG010000 permit. Docu5�"- ii S E C up E D Certificate Of Completion Envelope Id: D54AC7A52375454BA59BD993AE3054E1 Status: Completed Subject: Please DocuSign: NCG01-eNOI-Certification-Form-20210212-DEMLR-SW (Airport Road FSU #04655).pdf Source Envelope: Document Pages: 1 Signatures: 1 Envelope Originator: Certificate Pages: 1 Initials: 0 Sally Pierce AutoNav: Enabled 5200 Buffington Road Envelopeld Stamping: Enabled Atlanta, GA 30349 Time Zone: (UTC-05:00) Eastern Time (US & Canada) sally.pierce@cfacorp.com IP Address: 45.30.44.92 Record Tracking Status: Original Holder: Sally Pierce Location: DocuSign 4/29/2021 7:01:00 PM sally.pierce@cfacorp.com Signer Events Signature Timestamp John Mark Wood ly Sent: 4/29/2021 7:02:14 PM Johnmark.wood@cfacorp.com ED—Signed d (U' kot wbb Viewed: 4/29/2021 7:55:25 PM Chick-fil-A, Inc. BFA1466A3F324B3... Signed: 4/29/2021 7:55:36 PM Security Level: Email, Account Authentication (None) Signature Adoption: Pre -selected Style Using IPAddress: 76.17.118.245 Signed using mobile Electronic Record and Signature Disclosure: Not Offered via DocuSign In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 4/29/2021 7:02:14 PM Certified Delivered Security Checked 4/29/2021 7:55:25 PM Signing Complete Security Checked 4/29/2021 7:55:36 PM Completed Security Checked 4/29/2021 7:55:36 PM Payment Events Status Timestamps