NCC231497_NOI Signed Certification_20230524

BRUNS-2023-077
NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOI.
The , 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,6th 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 -•RlVI YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122'.22]
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement,representation, or
certificatio 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 pen.Ity of law, I certify that(check all boxes to indicate your agreement):
El I a the person responsible for the construction activities of this project,for satisfying the requirement;of this
pe mit,and for any civil or criminal penalties incurred due to violations of this permit.
13vTh: information submitted in this NOI is,to the best of my knowledge and belief,true, accurate,and co mplete
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
gat erling the information.
a I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Pla .
t e approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Pre ention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
per it are met on the project at all times.
EKI'h:reby request coverage under the NCG010000 General Permit and understand that coverage under this
per it,will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Project acme(must match Ala): Champion River Run Tract
Specific of Numbers(must match Alb):
Permitt:e(must match 81): Roger Pierce and Roderick L. Wilkins
Legally 'responsible Person (must match 82&83): Property Owners
iTitle of egally Responsible Person (must match 83b):
Name&Title of Signed if Authorized Individual
Differs f om Legally Responsible Person:
Phone N mber: 910-624-9222 /910-316-2112
Slit/-23
S gnature of L gaily Responsible Person or Authorized Individual Date
* IMPORTA T NOTE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a .resident,secretary, treasurer,or vice president, or a manager that is authorized in accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.

BRUNS-2023-077
NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOI.
The ,mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)3t:
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 UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE ••RM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122 22]
P r NC Ge erall Statute 143-215.68(i), any person who knowingly makes any false statement,representation, or
ccrtificatio 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 pen.Ity of law, I certify that(check all boxes to indicate your agreement):
Eg' I a the person responsible for the construction activities of this project,for satisfying the requirement;of this
pe mit,and for any civil or criminal penalties incurred due to violations of this permit.
Th: information submitted in this NOI is,to the best of my knowledge and belief,true, accurate, and co rplete
ba ed on my inquiry of the person or persons who manage the system,or those persons directly resporsible for
gat erling the information.
Er I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Pla .
J- If t e approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Pre ention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
per it are met on the project at all times.
▪ h-reby request coverage under the NCG010000 General Permit and understand that coverage under this
per it will constitute the permit requirements for the discharge(s)and is enforceable in the same manr er as an
individlual permit.
Project Name (must match Ala): Champion River Run Tract
Specific _ot Numbers(must match Alb):
Permittee (must match 81): Roger Pierce and Roderick L. Wilkins
Legally Responsible Person(must match 82& 83): Property Owners
Title of Legally Responsible Person (must match 83b):
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 910-624-9222 / 910-316-2112
3
S gnature of Legally Responsible Person or Authorized 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 8,
Item(6)of the NCG010000 permit.