NCC240291_NOI Signed Certification_20240209

NCGOI Notice of Intent NO! Certification Form
Directions
Pci"rrt this form,complete,:Scan and upload to tite electronic.N0i.
Then,Menthe oitiginal form to the'NC DEMLR StormWater Program(with$12-0 check if paying by check)
at:
Division of Energy,Mineral&Land Resources Stormwater Program
512 N.Salisbury.Street,601.Floor(Office-640K)..,
1612 Mail Service centers
Raleigh,NC 276994612
¢ , t
I C �
•e.2.t ,eb. 5„ .,e. a..,sA,�.,F.v , ,n..„ ..v»,,. :�.R...> ......,.f v ,,,. r>•x
Per NC General Statute 14.N154B(i), any person who knowingly makes any false statement, representation,or
certification in any application,record, repart,plan,or other docent filed or required to be maintained arid 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( 4O,000).
Under penaltyat' w,I cent certify .tlidticf'teck aIFboXes to indicate your agreement):
[]✓ I am the person responsible fOi 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.
0 The Information submitted in this NOI is,to the::best of my knowledge and belief,true, accurate,and complete
baaed;on my inquiry of the person or persons who manage the system,or those persons directly responsible for
gat hel`Itrgthe information.
0 I will abide by all conditions of the NCGO1 ` ' -' i i-rrnit and the approved Erosion:and Sediment Control
Plan.
P
GE if the approved ErosionandSediment Control plans not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG01000 Genet , ' `. - I Will nonetheless enSure that all conditions of Part.II of the
permit are met on the project at all times. :-' ''''"
d I hereby request coverage under the �Ra 1r t and understand that coverage under this
permit wilt constitute the permit regtiU rein httheir the clis�rr1e(s)'and is enforceable ip-the same manner as an
individual pre r rift..
Project Name(mn;match A1a). HURRICANE HOLE
Specific Lot Num#ers(must rnat
Perrrrittee(must match B :),Alter Management, LLC
- i , . --- ' ':i
,eg l Responsible PeIFon(Must m itch B2&B3): Michael Edwards:.
Title of Limit+fie nsibie Person(must Moth,630 Managpr
Print Name&Tale of Signed if Authorized.
Indio dual Dierafrorn;Legally Resonsible.Person:
. `one.Mim er (919) 90 2 ......
Si nature of'Legatbi flees risible•Person or Authorized individual Da e
-' * IMPORTANT NOTE: This Om must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president,secretdry,treasurer,,or vice president,orasi?nanager that is authorized in accordance with:Part IV,Section B;
item(6)afithe dtrile t permit,