NCC230427_NOI Signed Certification_20230215

NCG01 Notice of Intent (N0Q Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEM LR Stormwater Program (with $100 check if paying by check) 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 OR PAYMENT UI\ITII YOUR APPUCAJION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22)
Per NC GeneralStatute143-215.6B(il any person who knowing lynakesanyfalsestatementrepresentationpr
certificatiorin any application,record, report, plan, orotherdocumentiledorrequiredto be maintainedunderthis
Articleora rule implementinghisArticle... shallbe guiltyofa Class2 misdemeanowhichmayincludeafinenotto
exceedten thousanddollars{$10,000}.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
® I an 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.
0 The information submitted n 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.
IN I will abide by all conditions of the NCGOIC000 General Permit and the approved Erosion and Sediment Control
Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part I (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part I of the
permit are met on the project at all times.
® I hereby request coverage under the NCGOIC000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s) and is enforceable n the same manner as an
individual permit.
Name of Project (must matchAla): Contractor's Yard - Edwards
Specific Lot Numbers (mustmatchAlb): n/a
Legally Responsible Organizational Entity (mustmatchBl): Iron Creek Investments, LLC
Legally Responsible Person (mustmatchB2& 133): Jonathan D. Edwards, Jr.
Title of Legally Responsible Person (must matchB3b): President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: [phone]
4��
Signature of Legally Responsible Person or Authorized Individual
ate
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such a; a president, secretary, treasurer, or vice president, ora manager that is authorized in accordance with Part IV, Section 5
Item (6) o f the NCG010000 permit.