NCC221682_NOI Signed Certification_20220523

NCG01 Notice of Intent (Nofy Certification Form
Directkitrs:
Print this form, complete, scan and upload to the electronic NC)I
Then, mad the original form to the NC DIE MLR Stormwater Program {with 5100 check if paying by check} at
Divuianof Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6• Floor IOffxe 640K)
1612 Mail Service Center
Raleigh, NC 276"-1612
DO NOT MAIL THIS FORM OR PAYMFNT UNTIL YOUR APPLICATION HAS 81tN ACCEPTED ASCOMPtETE.
THE FORM YOU MAIL MUST BE COWL ITED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL)140 CFR 122-221
PCO' NC GenewlStatute 143.2IS.69 tol any person who knowirryly makes any fotsa statement, ►rp►csrr>dat►an, a►
certification rn any ap0kotkn record, report, plan, or other document filed or required ra be mairitahwd under this
Artx* or a rulr unphrrnenring this A►tkit ... shall be guirry of a Class 2 misdemeanor uWh►ch may include a Ime not go
exceed fen thousand do0ors ($JQOW).
Under Pen#Ply of law, I certify that (dWik all poxes It indicate your agreement)
[] I am the person responsible for the construction actnerties of this protect, for satisfying the regW►enwrits of this
permit, and for any clv+l or criminal penalties incurred due to violations of this permit.
E) The information submitted in thu NOI is, to the best of my knoviledge and belief, true, accurate, and complete
based on eery inquiry of the person or persons who manage the system, of those persons directly responsible for
gathering the information-
0 I wilt abide by all conditions of the NCGO I XQQf&njttLpand the approved Erosion and Sediment [vetted
Plan.
✓0 tf the approved Erouon and Sediment Control Plan rs not compkmnt with Part II [Sio(mwater Pollution
Prevention Plan) of the Ne C, 12Q2p -QK-n&r, l pesmrt. I will nonetheless ensure that all conditions of Part II of the
permit are met on the protect at all times.
[] I hereby request coverage under the NCG01M GtWO Permit and understand that covrrage under this
permit will constitute the Permit requirements for the drschargejsj and is enforceable in the same manner as an
indrvidual permit -
_Proffer! Name (must ff4tch A]a): Del Webb at Cale'b's Creek
5 c lot Numbers (must match Alb): 6874-64-2955.OW
Permr"re must match 81 ; SOMA North Carolina, U-C
Legally Responsible Person 4must march 82 & 84. KDry Reimann
Title of L!jatly Responsible Person (rrrust match Bib : Manager
Name & True of Signed if Authorised IndNi"
Differs from Legally Responsible Person:
Phone Number: 3p7-s"-4749
I�JA
Lure of Legally Responsible Person or Authorized Individual
7a
Date
AWPOITTANTMQTE: TPirs forest nwst br tlpned 6y a resparrl�bfe torparott ofjFcrr dial awls a operates the construction act�Nty,
tech as a president; Setrerarv. t►riasurrr nr urr n�.e�...r .,......,._---- •�-- .- _-.-. _ - - ..
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