NCC230839_NOI Signed Certification_20230328

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOi
Then, mail the original form tothe NCDEK4LRStormowaterProgram (with $1UOcheck /fpaying bycheck) at:
Division ofEnergy, Mineral & Land Resources StonnwaterProgram
512N. Salisbury Street, 6'^Floor (Office 64OK)
1612 Mail Service Center
Raleigh, NC27699-1612
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 122.22]
Per �General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification inany application, record, report, plan, orother documentfilednrrequired tobemaintained under this
Article urorule implementing this Article ... shall beguilty oƒoClass 2misdemeanor which may include ofine not to
exceed ten thousand dollars ($20,000).
Under penalty of law, |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 requirementsof this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
Fv-,l The information submitted in this NO| is, tothe best ofnyknowledge 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
F�l If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, | will nonetheless ensure that all conditions ofPart Uofthe
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.
Name (must match A1o):Old Mill Village -Lot 5
Lot Numbers (must match Alb): Lot 5
Permittee (must match Bl): North Carolina ULP
Legally Responsible Person (must match B2 & B3): Eric Rifkin
Title of Legally Responsible Person (must match B3b): Vice President
Name & Title nfSigned ifAuthorized Individual
Differs from |
Phone Number: 919-387-1885
neofLegally Responsible Person orAuthorized Individual
':Z+ 14, g�
Date
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such asopresident, secretary, treasurer, or vice president, momanager that is authorized in accordance with Part IV, Section B,