NCC214497_NOI Signed Certification_20210827

NCGO1 Notice of Intent (N01) Certifat
ication For
Arfv.-Icle or a rule implementing this Article ... sho
exceed ten thousand dollars ($10,000).
Uncle
r penalty of law, I
Directions:
Print this foirm, complete scan and uploao to the electronic N01-,
Then, mail the original for` 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, 6th Fgoor (0;�i.::e 640K)
1612 Mail Service Cente,4:1
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE
I HE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NUT DIGITAL) [40 CFR 122.221
Per N C General Statute 143-215.6B (i)., cn y person who knowingly makes any false statement, re orese n to tio nq o r
certification in any application, record, report, plan, o r other document filed or required tn h P maintnined under t h ic
N De guilty of a Ctass 2 misdemeanor which nay include ra fine not r
o
a
certify that (check all boxes to indicate your agreement):
�sp�azsible for the construction activities of this nroiect, far satisfying the requirements of this
permiL. anCl Tor any civil ot- criminal
i arm the person r
ir
The information subm
based on my inquiry o
gallherl
penaltiesincur.reddue to violations of this permit,,
i}ted in t}�is N01 is, to the best- cif my knowledge and belief, true, accurate, and complete
f the person mro:ersons who manage the system, or those persons di--���l�,< respons:ible for
ng the intormation.
I wiell abide by a
P1 .
II conditions of the NCGO10000 General Permit anti the approved Erosion and SgEhdiment Control
�7 If the approved Erosion and Sediment control flan is nest compliant with Part it (Stormwate,�,- Pollution
Prevem'.1on Plan) of the NCG010000 General Permit, 1 will nonetheless erasure that all conditions of Part i1 o-11 the
perm�t are met or the pro*ect at a!I times.
jC 1 hereby requesti cove rage order the NCGO 10000 General Permit end understand that cove rage under this
perrr,a will constitute she permit requirements for the discharge(s) and is enTorc:eable in the same.. manner as an
IN permn.,.
Name of Project (must .match Alo):,
Grayson Parck Phase 1 C sec�or� 3
Specific Lot Numbers (must match Alb):
Legally Responsible Organizational Entity (must match Bl): Grayson ParkDe...velor.Dlment LLB
Le gall�i Resptar�si b 1 e Per-sc�n (must match B2 & B3): Steve Shuttleworth
Title of Legally Responsible Person (must match B3b): Managing Member
Name & Title of Signed if Authorized Individual
lifters from Legally Responsible Person:
P I FAW %--
Signature ot legally Responsible Person or Authorized Individual Date
* IMPORTANT NOT!�T: This farm must be signed by ores ponsibleco rporateofficer that owns or operates the construction activity,
5uchaso president, secretory, treasurer, or vice president, or a manager that is authorized in accordance with Part iV, Section 8,
Item (6) of the NCG0i.u000 permit.