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HomeMy WebLinkAboutNCC215916_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20230921 NCGO1 Legally Responsible Individual Change Form Use this form when: The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name or ownership. **If the project name has changed, or if the ownership of the project has changed, do NOT use this form.** Instead,you must submit a new NCG01 electronic Notice of Intent (eNOI). Directions: Print this form, complete,scan and upload to the Construction Stormwater Permit MODIFICATION Form. Then, mail the original form to the NC DEMLR Stormwater Program 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 UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE. THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22] Certificate of Coverage (COC) Number: NCC215916 Name of Project: FDB Project Galaxy - Early Grading Legally Responsible Organizational Entity: Fujifilm Diosynth Biotechnologies USA, Inc. PREVIOUS Legally Responsible Individual: Thomas Schmalzbauer NEW Legally Responsible Individual: Jordan Ulrich The following section is to be completed and signed by the NEW Legally Responsible Individual. Per NC General Statute 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 2 misdemeanor which may include a fine not to exceed ten thousand dollars($10,000). Page 1of2 NCGO1 Legally Responsible Individual Change Form THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22) Under penalty of law, I certify that(check all 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. ® I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control Plan. ® If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the permit are met on the project at all times. ® I 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. ® This form has been reviewed and is accurate and complete to the best of my knowledge. *Signature: Date: 20SEP2023 Print Name of Signed: Jordan Ulrich Title: Vice President of Project Delivery Mailing Address: 101 J Morris Commons Lane Morrisville, NC 27560 Street Address: 101 J Morris Commons Lane Morrisville, NC 27560 Email Address: j ordan.ulrichc:2)fuj if ilm.com Phone Number: 419 . 266 . 9596 * 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 NCG010000 permit. For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit. Page 2 of 2