NCC241346_NOI Signed Certification_20240507

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOi
Then, mail the original form to the N[DEMLR Stormwater Program (with $lUO check/y paying bycheck)at:
Division of Energy, Mineral& Land Resources Stormwate/Program
SlJN. Salisbury Street, 6* Floor(Office 64OK)
l612 Mail Service Center
Raleigh, N[27699'1612
00 NOT MAIL THIS FORM 00 PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED ASCOMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CIFIR122'22]
Per N[General Statute 243'225.68(i), any person who knowingly makes any false statement,representation, nr
certification in any application, record, report,plan, or other documentfiled or required to be maintained under this
Article o,o rule implementing this Article. . . shall be guilty o/o Class J misdemeanor which may include oftnenot to
exceed ten thousand dollars ($2(l0DD).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
[V_� |en/the per-son responsible-for the construction activities of this project,for satisfying the requirements ofthis
pert-nit, arid for any civil or criminal penalties incurred due to violations of this pen-nit.
[� The inforrnation submitted in this NOI is,to the best of my knowledge arid belief,true, accurate, arid complete
based on my inquiry of the person or persons who manage-the system, or those persons directly resporisible for
gathering the information,
��
�� I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan,
If the approved Erosion arid Sediment Control Plan is riot cornpliant with Part 11 (Storrnwater 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 a!all times.
[�| I hereby request coverage tinder the NCGO10000 General Permit and understand that coverage tinder this
permit will constitute the permit requirements for the discharge(s)and is enforceable in the sarne manner as an
individual permit.
Project Name (must match A2o): EMH Imports
Specific Lot Numbers(must match Alb):
permittee (must match 82): EMH IOlOOrtS. LLC
Legally Responsible Person (must match B28\ B3): pChUseiO MoVIVUdOVichAliV8V
Title of Legally Responsible Person (must match 83b): OVVDe[
Name &Tide of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number. 704-941-8745
— -- ----- �_K
Si8notu,eotLeQa||yKespondb|e Person or Authorized Individual D art e
* 0MPORTANTN0TE: This form must be signed by a responsible corporate officer that owns or operote5 the construction activity,
such oxo president,secretary, treasurer, n/vice president, o/o manager that is authorized/n accordance with Part IV,Section B,
Item kVo/the NCG020000permit.