NCC230784_NOI Signed Certification_20230322

NCGO1 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, 6lh Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Per NC General Statute 143-215.6B (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).
Under penalty of law, I certify that (check ail boxes to indicate your agreement):
❑✓ 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 NOl 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.
❑✓ I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
M if the approved Erosion and Sediment Control Plan is not compliant with Part II (stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, l will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
0 I 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): South Selma Regional Pump Station & Forcemain
Specific Lot Numbers (must match Alb): See attached lot number list
Permittee (must match B1): Eastield Associates, LLC
Legally Responsible Person (must match B2 & B3): Kevin Dougherty
Title of Legally Responsible Person (must match B3b): Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-965-5661
3X/0 2
of Legally Respon ' erson o# Atfthorized 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 IV, Section B,
Item (6) of the NCGO10000 permit.

SOUTH SELMA REGIONAL PUMP STATION
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
LISTING OF IMPACTED PINS
14N99006F— Donald Carol Hull, Phyllis Larue Hull
o 260412-85-8481
• 14057027G —Johnston Square Associates LLC
0 260412-86-2024
• 14057009 — Nell M Howell Revocable Trust
o 260407-57-1688
• 14044022A —Paul H Howard
o 260408-88-3830
• 14M10089—Paul H Howard
o 260408-89-3389
• 14044022—Pau l H Howard
o 260408-89-4810
14001015D-- Robert W Williams, Jane Williams Davis
o 260520-70-7294
• 14054010P — Sysco Food Services of Rat LLC
o 260504-60-4924
• 14057009Y — Tow n of Selma
o 260504-62-5795
• 14057012C — County of Johnston
o 260504-62-8239
Saved Parcel Information
(& Delete Checked - Delete All
%ISy Actions
Tag
NMn
Mapsheet tto
Owner Name I
121•i11019
251404.42-4067
2614
EASTFiELD ASSOCIATES LLC
12MI2004K
261414-44-1722
261414
EASVIELD ASSOCIATES LLC
12t�112003
261414.43-240
261414
CROCKER, JOSEPH MEU-fl!LLE
.J
14F11200IC
261414-33-1808
261414
ASDALLA, MICHAEL 3 SR.
,— [4 C4 t io
14LI00141
261414-23-9958
261414
ABDALLA, '-1ICHAEL 3 SR.
{ .�
121.112004M
261414.34.2420
261-114
P x L PROPERTIES OF 3OHt1STON, LLC