NCC241008_NOI Signed Certification_20240404

NCGO1 Notice of Intent (N01) Certification Forrn
Directions-
Print this form,complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with$120 check if paying6vchecN
at:
Division of Energy, Mineral & Land Resources 3tormnvveterProgram
512N.Salisbury Street,Gm Floor(Office 64OK)
1612 Mail Service Center
Raleigh, NCJ7G99-1612
THE FORM YOUkMAIL MUST BE COMPLETED WITH 40,4 ORIGINAL S1Gk,*,.TURE(NOT DIGITAL) [40 CFR 122.221
Per NC GeneralStatute 143-215.6B(i), any person who knowingly makes anyfolse statement, representation, or
certification/n any application, record, report,plan, or other documentfiled or required to be maintained under this
Article oru rule implementing this Article. . .shall 6e guilty ofmClass 2 misdemeanor which may include o fine not to
exceed ten thousand dollars/$21\00].
Under penalty of law, | certify that(check all boxes to indicate your agreemment):
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.
Fv-,l The information submitted in this NOI 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, or those persons directly responsible for
gathering the information.
��
c�/ 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 11 (Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
I hereby request coverage under the NCGO 3.0000,Genera I Permit and 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.
Project Name (must match A1a): GreeMHil| Ph@Se1
Specific Lot Numbers(must match A1b\:
Pernnit1ee(must match 81\: Starlight Homes North CaPo!iMa, LLC
Legally Responsible Person (must match 83f& 83>: Raymond Rinker
Title of Legally Responsible Person (must match B3b): Vice President DfLand Development
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person: [@Ur8M Granger, Land []eV8lQpA9eMf Manager
Phone Number: 919-616-5347
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Sig6a�1meofLe�a|k/ Respc�sibh�PersnnorAuthorimed |ndiv�dua| Date
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* /MPORTA/VTNOTE.- This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such uao president,secretary, treasurer,or vice president, nro manager that is authorized/n accordance with Part IV,Section 8,
Item @1uf the N[GO1U000permit.