NCC213698_NOI Signed Certification_20210621

6116512021
New Submission
r,ioRrH CAROLINA
Environtnontof Quality
Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North Carolina's
General Permit NCGO1 0000: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
A. Project Information I B. Pernniftee Information I C� Site Contact information I D. E&SC Plan
E. Certification
North Carolina General Statute 1143-215.613 (1) provides that:
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; or who knowingly makes a false statement of
a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate
any recording or monitoring device or method required to be operated or maintained under this Article or rules of the Commission
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�
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.
12 The information submitted in this NO1 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 NCGO10000 General Permit and the
approved Erosion and Sediment Control Plan.
12 If the Erosion and Sediment Control Plan approved by the delegated program
is not compliant with Part 11 (Stormwater Pollution Prevention Plan) of the
NCGO1 0000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I hereby request coverage under the NCGO1 0000 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.
https:/Iedocs.deq.nc.gov/FormsiNCGOl-NO] 112

6/16/2021 New Submission
Siaecifyifyouare.* VYIhe Legally Responsible Person named on this Notice of Intent
Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
Important: The person who electronically signs (his Certification above must be the same person who signs the NOI
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized
responsible person within the same organization as the Permittee. *An authorized individual is a responsible corporate
officer who owns or operates the construction activity, such as 2 president, secretary, treasurer, or vice president, or a
manager that is authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 General Permit. For
more information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature
T
Type Name Fo­-n� G. �ohnson
Title rPresident
Organization Legally Responsible Entity
M J Developers, Inc.
Date Date captured on form submission
F---'
Previous
I'm not a robot
reCAPTCHA
alms
Submit Save as Draft
httn'Z-/1�0— A—