NCC231554_NOI Signed Certification_20230526

NC_GOI Notice of Intent (N01) Certification form
Print thit. to!t#, [.°mill ` = l .'1+1`! a lie ti,e electronic NOI.
Then, mail the original form Itt u„ NC. UIMI i ,ttttI, nate, with 301")checIKif; '.Trig bychpckj at.
Division of I of tl};y,Mirti >il & land Rr•.: tr,rrnw4t' Progrbr:
..rlisbury t, 6" ( (AOK)
k.tl+ 11',L NC
DO NOT MAIL TtliS i c1fiM t it PAYMI.NT INN YOUR APPLICATION HAS BEEN A(CUPTED AS COMPLUF,
THE FORM YOU MAIL MUST RI,COMPiFT D WITH AN ORIGINAL.SIGNATURE (NUT DIGITAL) 140 CFR 122.22;.
Per NC General Stature 143-215,68(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 1 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
tinder penalty of law, I certify that (check all boxes to indicate your agreement;
E i am the person responsible for the construction activities of this project, for satisfying the requ:rement - of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
Q 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, rir those persons directly resporlsibie for
gathering the information.
E I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
E if the approved Erosion and Sediment Control Plan is not compliant v. h Part Ii (Stormwater Pollution
Prevention Plan)of the NCGO100O0 General Permit, I will nonetheless ensure that all conditions of Part ii of the
permit are met on the project at all times,
Lvji hereby request coverage under the NCG010000General rn.t and understand that coverage under this
permit will constitute the permit requirements for the discharges) and is enforceable in the same manner as an
;r-ri;ti'+dual permit
Highway 13 Mini-Storage
Project Name (must match Ala)
Specific Lot Numbers(must match Alh) _
PermittEe (muse march 81) Great Value Self Storage LLC
Permit tee
Legally Responsible Person (must match 81& 83): Robert T. Gamey
Title of Legally Pr-'.l oiv,rble Person (must match 83b): Managing Member
Name & Title of 'signed rl Aut hurried Individual
Urffer� trc,rn Lr.R,illy Rr''p'irt:ittlr Per son: _w w_...
803-412-47.82
PF,orrnp Numbr`r
Signal e of L. g, y Res nsiblc r_rson or Authorized Individual w.~ 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/V.Section B.,
item l6)of the NCG010000 permit
all 4 r i- " . :m. ,'