NCC222368_NOI Signed Certification_20220708

NCG01 Notice of intent (NCI) Certification Form
❑irections:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC ❑FMLA Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Storrnwater Program
512 N. Salisbury Stree(, 6­ Floor (office 640K)
1612 Mali Service.Center
Raleigh, NC 27699-1512
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWEC+ AN11 ACCEPTED A5 f OMPLETE
Per NC General Statute 143-215.i5B (l), any person who knowingly , -makes any false statement, representation, or
t:ertification in any appficatlan, record, report, plan, or other document filed or required to he maintained under this
Article or a rule implementing this Article ... Shall be guilty of a Cross Z misdemeanor which may Include a fine not to
exceed ten rhousond dollars ($10,000).
Under penalty of law, I certify that (check all boxes to Indicate your agreement).
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, anff for any civil or criminal penalties Incurred dice to vioiationti of 011s permit.
:2. The information submitted in this N01 is, to the hest of my knowledge and belief, true, accuratz,-arid complete
based on my inquiry of the person or persons wlro manage the system, or those persons directly respanS5ble for
gathering the information,
I will abide by all conditions of the NCGp1OX10Genera I Pe mit anti the approved Erosion and Sediment Control
Plan.
i if the approvers Erosion and Sediment Control Vldfv 4 not compliant with Pan 11 ( Storm water Pa#lution
Prevention Plan) of the NCGO10000 General Permit. f ►,ri11 nonetheless ensure that all conditions of Part II of-the-
permit.are mef on the project at all tunes.
I hereby request coverage under the NCGO10C ]ti General Permit and understand that coverage under this
permit will Constitute the permit requirements lot the disc harge(sl and is enforceable in the same manner as an
individual permit -
EVOLVE HOi-i.Y RIDGE RV
Name of Project (must match Ala)
EVOLVE RV HOLLY RIDGE. LLC
Legally Responsible 0rganixationaI Entity (must match B1)
WE WINSTEAD 'TC.
Legally ResporpiW Per gn (must match B2
MANAGER,-' f
Title of)J`Ily Re , nsibl P4,ion (must p�6tch B3b) ,
*Sigf
te
' Print Name and Title of Signed if Authorized Individual Differs from Legally Responsible Person
1.91W 235-9120
Phone Number
IMPORTAi T NOriw This form most be signed by a respvnsibir corporate officer that owns or operotes the Construction activity,
such as a president, secretary, treasurer, or vier president, or a manager that Is authorized in accordance with Port iV, Section $
item (6) of the NCG010000 permit. For more information on signatory requireme►its, see Port IV,, Section 8, item (6j of the
NC6010000 permit.