NCC230379_NOI Signed Certification_20230209

NCGO1 Notice of Intent (NOU) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at:
Division of Energy,Mineral & Land Resources StormwaterProgram
G12N.Salisbury Street, 6mFloor (Office 640K\
1612Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM 0R PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THEFORM YOU MAIL MUST 0ECOMPLETED WITH ANORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR122.22]
Per NCGeneral Statute 243-225.68(i),any person who knowingly makes onyfalse statement, representation, or
certification /nany application, record, report, plan, orother docunventfiledorrequired tobemaintained under this
Article ororule implementing this Article ... shall buguilty ofoClass 2misdemeanor which may include ofinenot to
exceed ten thousand dollars ($10, 000).
Under penalty oflaw, |certify that (check all boxes to indicate your agreement):
[71 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.
[�| The information submitted in this NOI 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 those persons directly responsible for
gathering the information.
| will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
�~ If the approved Erosion and Sediment Control Plan is not compliant with Port || (Stormwmter Pollution
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions ofPart ||ufthe
permit are met on the project at all times.
[71 | hereby request coverage under the NCGO10000 General Permit and 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.
Project Name (must match Ala): 3201 Wat8[fieid[)riVe
Specific Lot Numbers (must match Alb):
pennitLee(must match B2): A.B. Goodrich CDOt[@CtiDg, LLC
Legally Responsible Person (must match B2 & B3): Alferd Goodrich
Title ofLegally Responsible Person (must match 83b): President
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
2/8/23
Signature of Li-gally Resp-on-slbTe Pers—onor Authorized Individual Date
IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that isauthorized /naccordance with Part IV, Section 8,