NCC222370_NOI Signed Certification_20220708

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this farm, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR 5tormwater Program (with $100 check if paying by check) at;
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salisbury Street, 6f� Floor (Office 640K)
1612 Mail Service -Center
Raleigh, NC 27,699.1612
DO NOT MAIL THIS FORM OR PAYMENT
UNT11 YOUR APPLICATION HAS BEEN REVIEWED AND ACCEP'ED AS COMPLETE
Per IVC 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 ceet!N that (check all boxes to indicate your agreement):
91 am the person responsible for the construction activities of this project. for satisfying the requtrements of this
'permit, and for any civil or criminal penalties incurred due to violations of this permit.
The information Submitted in this NQI 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 thwie persons directly responsible for
gathering thr information.
r- I will abide by ail conditions of the NCGO10000 Ge-n"aI Perrttli Arid the approved Erosion and Sediment Control
4t n.
if the approved Erasion and Sediment Control Plan Is not compliani with Part I (51ormwater Pollution
PFRvention Plan) of the NCGO30000 Genera: Permit, I will nonetheless ensure that all conditions of Part 11 of the
emit are met on the project at ail times.
1 '' I hereby request Coverage under the NCGD10D04 General Permit arid understand that coverage under this
permit will constitute the permit requirements for the discharges) and is enforceable its the same manner as an
individual permit
EVOLVE HOLLY RIDGE RV PHASE 2
Name of Project (must match Ala)
EVOLVE RV HOLLY RIDGE, LLC
Legally Responsible Organizational Entity (must match 81)
MIKE WINSTEADAR
Legally Resp nAle 13 (yin (mtq match 82 & 83)
MANAGER � �!
i
Title of Le P
fly Res onsibl rsa (must rrh Bab)
* 5igrta t+lr 1' Date
'Print Name and Title of Signed if Authorized individual aiffersfrom Legally Responsible Person
(910) 239-9i 2O
Phone Number
IMPORTANTiVOTE., This form must be signed by a responsible corporate officer that owns or operates the constructmn activity,
such as o president scrtrtary+, treasurer, or vice president, or a manager that is outhorued m accordance with Part W,5ection B,
Item (61 of the AtCG010000 permit For mare information on signatory repurrements, see Part iV. Section e, Item (6) of the
NC6010000 permit,