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Home My WebLink AboutNCC216201_NOI Signed Certification_20211206DocuSign Envelope ID: EADAA953-E263-4FD8-8386-4342A7A6F52C 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 ACCEPTED AS COMPLETE. THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221 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): Cv� 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. 67� 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. 67� I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control Plan. IV 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. C� 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 Project (must match Ala): Gastonia CFA Specific Lot Numbers (must match Alb): NA Legally 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: NA Phone Number: (404) 765-8000 �ocu� ��ig�lffy: ,' 1 bLw I 0bb/,i. 10/28/2021 I 9:28 PM EDT raus�ae3... 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. DocuSign Certificate Of Completion Envelope Id: EADAA953E2634FD883864342A7A6F52C Subject: Please DocuSign: NCG01-eNOI-Certification-Form-20210514-DEMLR-SW (2).pdf Source Envelope: Document Pages: 1 Signatures: 1 Certificate Pages: 1 Initials: 0 AutoNav: Enabled Envelopeld Stamping: Enabled Time Zone: (UTC-05:00) Eastern Time (US & Canada) Record Tracking Status: Original 10/28/2021 9:25:33 PM Signer Events John Mark Wood Johnmark.wood@cfacorp.com Chick-fil-A, Inc. Security Level: Email, Account Authentication (None) Electronic Record and Signature Disclosure: Not Offered via DocuSign In Person Signer Events Editor Delivery Events Agent Delivery Events Intermediary Delivery Events Certified Delivery Events Carbon Copy Events Witness Events Notary Events Envelope Summary Events Envelope Sent Certified Delivered Signing Complete Completed Payment Events Holder: Sally Pierce sally.pierce@cfacorp.com Signature E DocuSignetl by: BFA1466A3F324B3... Signature Adoption: Pre -selected Style Using IPAddress: 73.106.88.29 Signature Status Status Status Status Status Signature Signature Status Hashed/Encrypted Security Checked Security Checked Security Checked Status Status: Completed Envelope Originator: Sally Pierce 5200 Buffington Road Atlanta, GA 30349 sally.pierce@cfacorp.com IP Address: 45.30.44.92 Location: DocuSign Timestamp Sent: 10/28/2021 9:26:48 PM Viewed: 10/28/2021 9:27:55 PM Signed: 10/28/2021 9:28:06 PM Timestamp Timestamp Timestamp Timestamp Timestamp Timestamp Timestamp Timestamp Timestamps 10/28/2021 9:26:48 PM 10/28/2021 9:27:55 PM 10/28/2021 9:28:06 PM 10/28/2021 9:28:06 PM Timestamps