NCC230593_NOI Signed Certification_20230316

CGO1 Notice of Intent (NOI) 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 $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6t, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTEi) AS COMPLETE.
T l$TI 1e aRlUR (NOT € I ITAL) (0 CFR 122,221
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation, or
certificotion in any application, retard, 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).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
�✓ l 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.
0 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.
0 I will amide by all conditions of -the NCGO10000 General, Permit and the approved Erosion and Sedirent Control
Plan.
0 if the approved Erosion and Sediment Control Plan is not compliant with Part Il (Stormwater Pollution
Prevention Plan) of the NCGO1000 -General Permit, I will nonetheless ensure that all conditions of Part If of -the
permit.are met on the project at all times:
0 I hereby request coverage under the NCG©1.0000"General Permit and understand that coverage underthis
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
Project`Name (mustmotchAla): Clementine Ridge.
Specific Lot Numbers (must match Alb): 1-
Permittee (must match BI): Riverfront Ventures, i_LC
Legally Responsible Person (must match 82 & 83): Justin Nifong
Title of Legally Responsible Person (must match B3b): Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Nu er: 704 562 5012
8/16/22
Signa o Legally Responsible rson or Aut.6c iced Individual Date
* 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 1V, Section B,
Item'(5) of the NCG010000 permit.