NCC242387_NOI Signed Certification_20240806

NCGO] Notice of Intent (NO1) Certification Form
nit et lions
Print this Col m.complete, scan and upload to the elettronu NOt,
Then Tail the original form to the NC IX MLR Stormwater Program(with$120 check rf paying by check)
at
Division of Energy, Mineral& Land Resources Storrnwater Program
512 N Salisbury Street.6'Floor(Office 640K1
1612 Mail Service Center
Raleigh, NC 27699.1612
Per VC Genera!Statute 163-215,60 la), any person who knowingly makes arty false statement, representatro.n, o✓
car,)cation im any application, record, report.plan,or other document filed or required to be maintained under this
Ar'rtle or artie imoJementirng this Article __shall be guilty of Class 2 m!sdemeonor which may include a fine not to
eirceeo ren thousand do(!ors ($10,000)
Under penalty of law,I certify that+,checii all bowels to Indicate your agreement)
v0 I am the person responsible for the construction activities of this project,for satisiytng the requnements of this
permit.and for any civil or criminal penalties incurred due to violations of this permit
[]✓ -ne information submitted in this NOI is,to the best of my knowledge and belief,true,accurate, and complete
bated on my inquiry of the person or persons who manage the system.or those persons directly responsible for
gathering the information,
❑✓ twill abide by all conditions of the ticc,_i 10000 Gr i.r,: Per rti c end the approved Erosion and Sediment Control
Part_
Q if the approved Erosion and Sediment Control Plan is not compliant with Part II(Stormwater Po-Iut,on
P'e.,ention Plan) of the fiCCiU1Z OOQ General Permit, I wi:1 nonetheless ensure that all conditions of Part II of the
p+rrrmit are met on the project at all times.
Q✓ i hereby request coverage under the ttCls'J 1OQQQS1rnsrral Pnl rt.ij and understand that coverage under this
permit will constitute the permit requirements for the discharge(%) and is enforceable in the same manner as an
individual permit,
Protect!tame(must match Ale). Oak Crossing
Specific Lot Numbersimust match A2tsj: 1-21
Permittee lmust match 82): WJH LLC
Legally Responsible Person lmust match 82& 83)7 Kurt Staw8t2
Title of Legally Responsible Person(must match 83b): Regional President
Print Name& Idle of Signed if Authorized
Individual Differs from Legally Responsible Person
Phone Number 7 04--I ll S-1 1 M
_
of legally Report ersan or Authorized Individual Dat
• IMPORTANT NOTE: This Jbrm must by a responsMle corporal,officer that owns or operates the comma-non o;tfory,
such as a president, secretary,treasurer.at vice president, or a manager that is outhorited 1h accwdonce with Port IV,Sectio.r 6.
Item!6!of the NCG010000 permit,