NCC223521_NOI Signed Certification_20221013

NCGO1 Notice of Intent (N of) Certification Form
Directions:
Print th is fo rm, com p I ete, sca n are d u pload to the a leetron i c NO I .
Then, ma 11 th e o rigi na I to rm to th e N C D EM LR Stor rnw-ate r P rog ra m (with $1C0 check if payl-ng by check) at
Division of Energy, IVlineraI & Land Resoorees Stormwater Program
512 N. Salisbury Street, 61h Flair (Office 0 )
1612 M a it Service Ce nter
Raleigh. NC 27699-161
DES NOT MAILTHIS FORM 0R PAYPAENT UNTIL YOUR APPLICATIGN HAS BEEIN ACCEPTED AS CO MPLETE.
TH E FOR M YOU MAI L M UST 8 E CO M RLETE D WITH AN 0 RIGOtAL SIGNATUR E ( NOT DIGITAL) [40 CFR 122.221
Per NC Generuf Statute 143.215, 6B fir), (rny rs-err who knowingly makes any false stnterrrent{ represerrEotron, or
certifocatrarr in any application, record, repaM pfun, or other docvrr i en t filed or required to be maintained under thi5
Article or a role implementing this Article ... shot) be guikly of a Class 2 rrrisderrreenor which may include o fine not t )
exceed ter thousand dollars ($11), -0).
Ll n d e r penalty of law, I certify that (c-heck all boxes to indicate your agreement):
0 I am the person responsible for the construction actilvities of this project, for satisfying the repuircments of this
permit, and for any civil or crirni na I penalties incurred due to violations of this permit,
n The -Information submitted in this N 0 1 is, to the best of my knowledge and belief, truer accurate, and complete
based on my inquiry of the person or persons who rnanage the system, or those persons - directly responsible for
gathering the-1nforrn-ation .
❑ 1 will .abide by al I conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Rle n.
❑, If the approved Erosion end Sedirrhent Control plan is not compliant with Part II (Stormvvater PolIut1an
Prevention PIS ri) of the NCGO10000 Generai.Permit. I will nonetheless en5u re that all cond itions of Part IG of the
permit are met on the project at all times_
Q I hereby request coverage tinder the NCG010000 General Permirt and understand that. coverage under this
permit will constitute the permit requarernent5 for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project Name (mast mach Ala); Do me S Ite DeveIc)pment
Specific Lot Numbers (must match Alb);
Pe rrn itte-e f m ust rnctc r gl �- Rafidy B u ch a n a r
LegaIly Responsible Person (mrestmatch 82 & 83): Flandy Buchanan
Tide of Lega Ilyr Respons i b l e Pe rso n (rrrus t match h3b); Own o r T
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person_ BI�Clrl1+r11'
Phone Nufnher: 8 B`443-474
signature # Legelly Resporisible Person or Authorized Individual
I 10/22
0/
Date
* IMPORTANTNOTE. T#rfs forM MUst be 5rgned by a responsible corporcrte officer thot own.5 or operates the construction octrvrtyf
5och as a president, se-Vet-ary, VeoAfferf or vice pre,5jd,- +t, or a manager that is authorized is accordance with Part 11}, Section 6,
Item (E� of the NCGOI Wpermit.