NCC231073_NOI Signed Certification_20230417

NCG01 Notice of Intent (N®11) Certification Form
Directions:
Print this form,complete, scan and upload to the electronic NOI.
Then, mail the ❑riginaI form to the NC DEMLR 5tormwater Program (with $100 check it paying by check)at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 60, Floor (Office 64.0K)
1612 (Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THF_FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) 140 CFR 122.22)
Per NC Genera'Siatute 143-21S.6B (i), ony person who kno,aiingly makes any false statement, representotion, or
certification in any application, record, report, plan, or ather document filed or required to be maintained under this
Article or a rule iMplernenting this Article. . .shall be guilty of a Closs 2 mis.derneanor which may include o fine not to
exceed ten thousand dollars ($1G,000J.
Under penalty of laver, I certify that (check ail I.G_xes t_o 'sr?=.1'caie­ov. rr ag 'ei-.e-—)
J
i aril the person responsible for the construction activities Of this project, For Satisfying the requirements of tills
permit, and for any civil or criminal penalties incurred due to violations of this permit.
The information subrnitted in this N 0 1 is, to the best of my knowledge and belief,true, accurate, and complete
based ors rrly inquiry of the person or persons who rnana;e the system, or tl?ose persons directly resaons!ble for
_
ggatheringLhC imormation.
Ln ,II r:l", \lr;.r =r-.9sir l-1 En SPrinnent �!l hI}•r V,l
;r i �ir� .,.� � . condt -;s of ti",e NCG07.Q0fl0 General Permit a'nd the , , __ - .
Plan,.
i t r the anpro`./ed Frosioi; and Sediment Control Plan iS ilot Co:mplin.i,1. With Pa'it II (Stor imwater Pol utloi-i
th
-ntion Plan) of `�e NCG01000.0 Gene ral Permit, I v ill nonethel-ss ensure t ._t all conci!tions of Part II of the
Pr��. ._ t;
permit are met on the project at all times.
,,, � � � �.. -age Lnrer lu
._ _ _ _. IersLard. Lllai Cove) tl-.:_
.:._I��� r�yuc�i cover�,b� un�l-i the NCG01{�OQO General Permit a!-.a
per m!t"iv
constitute the permit requirements for the discharge(s)ge(s) and is enforceable in the Same manner aS an
J:.. J.. I
1.Ulvi U dial perm
I IL.
Project Name (must match Ala):—T01""L, a r oal
Specific Lot Numbers (must match Alb).: a 9 --
11�i��eOlm flnde�rS �cS , LLCG
Permittee (must match 81).:9� -----.-�'.- —'—
I eslie groves
Legally Responsible Person (roust match B2 & B3)_ ---
Title of Legally Responsible Person (must match B3b): IV ISIO6r1 IPYe s IdP ._� —
Name &Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Pho Number: 910-486-4864
3J3o_Ia3
-� - -- — — Date
Signature of Legally espons!ble Person or Authorized Individual
S
* IMPORTANT NOTE: This form must be signed by a responsible corporate pfcer that owns or operates the construction activity,
such as o president, secretary, treasurer, or vice president, or a manager that is authorized in occordonce with Port IV, Section B.
Item (6) of the NC'GO10000 per'mit.