NCC220640_NOI Signed Certification_20220204

NCG01 Notice of Intent (NOI) Certification Form
Dlirectlona:
Print th is form. -complete, wa n a rid uploa d to the electronic N DI -
Then, mail the original form to the NC DEMLR Smrmwater Program jwith 6 100 check rf paying by check) at;
o ivk in n of 5nergy+, Mirle ra I & l;bnd Reza roes Storrnwater Program
S12 N. $allsbury $tree#, 6'" Floor (Office 0K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NO1 MAIL I HIS FORM OR PAYI1rILN7 U YT1L YOUR AITLICA r ION HAS BEEN ACCEPTED AS COMPILETE-
THL FCFRM YOU MAIL MUST BECOMPLLTLD1411H AN -ORIGINAL SIG NAIURL 1IN0T DIGITAL) j40 CFR 122,22]
Per NC General Ratute 143-215.68 er), any person who knowingly makes erryfi�sestatemest, representation, or
certifk-a con ir? -any upphcadon, record, report, plan, or other document f led - r required to be maintained girder tfiiS
Article -or a ride iniplerneritirlg this Articfe - . , shod be qud y of o Vass 2 misdemeamv which moy Mcfude o firm not to
exceed ten ftVSamd d0f+4jrs
Under penalty of law, I certify that (check all boxes to Indkote your reernenl);
0 1 am the Person responsible for the construction activities of this project, for satisfying the req ui rements of tfi is
permit, and for any civil or criminal penalties incurred due to violations of this permit.
❑ The information submitted in this NDI is, to the best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the person or persomwhD manage the system, or those per5Dns directly responsible for
gathering the information.
❑ I will a bi de by all cDnd ition5 of the N C581000D General Permit and t h e approved Erosion a nd Sediment Control
Plan.
0 If the approved Erasion and Sediment Control Plan is not corn pliant with Part II jStormwater Pollution
Prevention Pla n) of the NCGQ1GQ00 General Permit, I wil I nonetheless ensu re that all cond itions of Pa rt I I of the
permit are met on the project at all times,
Q I hereby request coverage under the NCGO10000 G eneraJ Permit and u nderstarwl that coverage under this
permit will constitute the permit requirements for the discharges) and is enforceable it the sarne manner as an
individual permit.
Project Name (most match AIo); Grime Edge Rear Property (Wake Forest holdings, LL - Tract 3)
$peClfiC Lot Numbe rs (Md$t MOtCh Alb);
Permlttee (mist Match 8j )_ We ke Fore 5t Hold i rigs, LL
L 11y Re-sj>onsible Parson (r usu mooch s2 & 83)= ,lames Duncan
TItle of LagaIly Respnnsifile P-Prson Imp sr nwech 83b]: Membar
Name & Title of Signed #f Authorized individual -
Diffefs from Leg -a I1V Respo ri 6ble Person; Jacob Anderson
Thane N umber:PM 9- $-J94$fi
5ignatur-efihneEdlij ResKsiible P
+ awaRrANTNorf. Phis
such as a pTesfdrenllSucre
jWM (F) of the N
212J22
Zed Individu a I
Date
must be signed by4:r riesponsibie carparate officer that owns or operates the awstruction acrWy,
Ireasurer, or vice praesiden� or manager rhat is ourhar+zedin accordance wirb Parr IV Sectian A
Permit.