NCC241695_NOI Signed Certification_20240605

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NQI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $120 check if payi g by check)
at:
Division of Energy, Mineral & Land Resources Stormwater Progr m
512 N. Salisbury Street,6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT 'IGiTAL) [ CFR 122.22]
Per NC General Statute 143-215.68(i), any person who knowingly makes any false stateme l t, 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).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
✓0 I am the person responsible for the construction activities of this project,for satisfy ng the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
l
E✓ The information submitted in this NOI is,to the best of my knowledge and belief,tr e, 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.
0 I will abide by all conditions of the NCG010000 General Permit and the approved Ermsion and Sediment Control
Plan.
E3 If the approved Erosion and Sediment Control Plan is not compliant with Part II (Sto mwater Pollution
Prevention Plan)of the NCG010000 General Permit, I will nonetheless ensure that a I conditions of Part II of the
permit are met on the project at all times.
Q✓ I hereby request coverage under the NCG010000 General Permit and understand th:t coverage under this
permit will constitute the permit requirements for the discharge(s)and is enforceab e in the same manner as an
individual permit.
Project Name (must match Ala): Woodlake Lots
Specific Lot Numbers(must match Alb):
Permittee(must match B1): DR Horton, Inc.
Legally Responsible Person (must match 82& 83): Neil Uldrick
Title of Legally Responsible Person (must match 83b): Division Stormwater Compliance Specialist Ill
Print Name&Title of Si ned if Authorized
Individual Differs fr Lega Respo le Person:
Phone Number 36 9240
r 1/24
Signature of Legally Responsible Person or Authorized Individual 1 Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or opera es the construction activity,
such as a president,secretary, treasurer,or vice president, or a manager that is authorized in accord 1 nce with Part IV,Section B,
Item(6)of the NCG010000 permit.