NCC222435_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20220830

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCGO1 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Certificate of Coverage (COC) Number: NCC222435
Name of Project: EMBASSY AT MOREHEAD CITY
ally Responsible Organizational Entity: HPG NC Morehead City, LLC
PREVIOUS Legally Responsible Individual: Nick Ciccone
NEW Legally Responsible Individual: Thomas C. Smith
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-235.6E (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).
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NCGO1 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Under penalty of law, I certify that (check all boxes to indicate your agreement):
E 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.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Contra! Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ensure that all conditions of
�f Part II of the permit are met on the project at all times.
I� I understand that coverage under this permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
Ly' This form has been reviewed and is accurate and complete to the best of my knowledge.
*Sienature:
Print Name of Signed: Thomas C. Smith
Title: Authorized Representative
Mailing Address: 802 E. 86th Street
Street Address: Indianapolis, IN 46240
Email Address: [e-mail]
Phone Number: 317-669-8404
Date: 8/30/22
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 6, Item (6) of the NCGO10000 permit.
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