NCC221440_NOI Signed Certification_20220413

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload tothe electronic N0i
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 StonnvvoterProgram
512 N.Salisbury Street, 6^ Floor (Office 640K)
1612Mail Service Center
Raleigh, NC27699-1612
DO NOT MAIL THIS FORM ORPAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR122.22]
Per N[General Statute 143-215.6BN,any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other documentƒiled or required to be maintained under this
Article urorule implementinghhisArticle...sho0begu8tyofnCkos2nnisdemeonorwhichmnoy/nckudeofinenotto
exceed ten thousand dollars /$1L\OOD/.
Under penalty oflaw, | certify that (check all boxes tmindicate your :
F71 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.
F-D | will abide byall conditions ufthe NCGO10000 General Permit and the approved Erosion and Sediment Control
[/-1 if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions ofPart Uofthe
permit are met onthe project atall times.
[�� | 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 inthe same manner as an
individual permit.
Project Name (must match Ala): Scaleybark Phase I
ific Lot Numbers (must match Al
Phase 1LLC
Legally Responsible Person (must match B2 & B3): Jeff Furman
Title of Legally Responsible Person (must match B3b): Managing Director
Name #' Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
ia bflAigdy Responsible Person orAuthorized Individual
*IMPORTANrNOTE. This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such asopresident, secretary, treasurer, n/vice president, momanager that is authorized in accordance with Part IV, Section B,