NCC241829_NOI Signed Certification_20240614

N CGO 1 Notice of intent (N 01) Certification Form
D rectior :
Print this fo.rrrj, nlplete,scan and upload to the e!Pctrori c IVOI.
TPrt.n, mail the original form td the NC DEMJJ3 Stprnriwater Program (with S121)diet*i poying by check)
at;
Division of br►erpy, Mineral& Land Ft riurCes Stormwater Prctgram
512 N_Salisbury Stre.et, FEr►nr{Office K0
1612 MarJ Service CerFter
gaIer h, NC 176 xbu
roTAI!MUST rot [C'fy'1 P LET D UViT't-f AN :•J61 r'i ii S.''rJAT1J RL (N07 t'IGrTZj} i•10 f5S
Per NC Ger]erg!s tatur 143-215_6H ri j, urry p;r_.u rt wh a kn o win glv mnkt a n}'fits a s tatemen t, repres ea tari pn, or
cErtiticotion ir;orr y app OicQ tJ ur,, retard,report,Maa, or other dracura E:it filed or required tc.)tre m i r?t-+7!n ed u hdE r rhiC
,1 rt'cfe or o rule iropierelentirig this A rvefz.-.shall be guilty of a Ck.23s?mis demman ur which may frrdude a fin e'o t ra
exceed ter)thousand darfurs f$1140010)_
Under E,wriat-ty cif law,I certify (h;4{chedr all boxes tt)indicate your atrr,ernerrt):
1 drtl I he person r ponlibie for the constructia n acrrvit ie.of this prajct, for satistying the requirrments of this
pr'rrret, and i,'or a;Iy r_ivil Or criminal pena Itias inrisrrcd Elise to iioi3tioni of this permit_
0 The inforrn3tian submitted in this htoi is,to the hest of my knovrtedge and belief,true,a-CCU raze, and arrrlpbele
F» rd on mvr ingiJiry fir tF►e person or i-Jerstuls who niar a iFtu sy-_,terrr, or thcrsr`i-p rs.or d irettly/c'_5rwrliible for
Eathiiirk Chr? intormaLion-
0 I will ahicf, by all conditions of the r_r�':;•v�t; :_ ,,:. r.;,= aocl Fbe approved Erosisn and`•ediirrer[L Control
Plan.
1-1 If ihr apprpkopc r erosion and Se'dimeri2 Con Lrul Plan is lE+)t Cofl pii:3r[t with P rt JJ (Strirmv,i tei Po114463r1
Prtwe nLion Plan)of LFtt =6. 'I =..' i I .'rr'i;• I wiEl nonc•th:71t:•_:.urir;ure that all Conditions at Part 13;iF r+ii•
permit Dre rntt DR thp project at all brnes_
fl I her�-Fty segue:t coverage u11dr'[ rllQ '�? 1 .',', i_ r -. rrT i? nd understand that COS:nagt ❑orter this
perm! wilt rnn,tittrte the permit req+llrei r irts for the di ftjrr;e(S)and i; erifprceahri in the sam winner as a n
ir>drvidual permit,
Project Name (+nor mutt/7 Ala)_ Hanes Meadame;
specific Lot Numhert(must Mord)Alb):
F'�r_llittre{must rnatch Si): Hanes adowspAirlMt* L.-L c
tefril}y RrISpOnsible Person (rrlust rnbtch 2 4 83]; Carl Cain
Title of h otly Responsit Per'Son{mom rr+otih fi b)_ Preside�lt
Print Ninie T;Il4- of Signed if A,uihorkr-ii
IndFvid Liar Differ$from Legally ResrrcbLe Person: Carl Cain President
Phone N ur tbes; 3<6- -3083
LftSignatisr'c of a Ity Respon a Per;,�n or Autr,orizt�tl Individual ��1 Date
lMP iRt 'T NOTE: Thrs Juan rust tre signed by a re.spositie[vrpnrate officer;Pao!cpwrIs or operate::the ian.---truC or1 oC�rvrlV.
crfc h as a e-r..i i dear .S L L re Cory, ere a-rw er,or vice presiden 1,of ft rfu rro ger that n d21:hel eiii e i n oc'rrianc nth Purt At;See tiC rl 8,
nern(f.),7f The rJCG?160010 pti-rr)iL