NCC242423_NOI Signed Certification_20240812

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 paying by check)
at:
Division of Energy,Mineral& Land Resources Stormwater Program
51) N. Salisbury Street,6t"Floor(Office 640K)
161,2 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOl MAIL MIISi RE IOMPLE i F L?WITH AN ORIGINAL SIGNATURE (NOT DIGITAL)(40 CFR 122.221
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement,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):
✓❑ 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.
✓(� 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.
Ell will abide by all conditions of the and the approved Erosion and Sediment Contro
Plan.
Q✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the , I will nonetheless ensure that all conditions of Part II o
permit are met on the project at all times.
Q✓ I hereby request coverage under the
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 Ala): Bynum Farms Subdivision
Specific Lot Numbers(must match Alb):
Permittee (must match al): Britt Development Co of Archdale, LLC
Legally Responsible Person(must match B2& B3): Dale Britt
Title of Legally P
Responsible Person (must match B3b): Owner
Print Name & Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number:
Date
Signat r of Legally Responsible or Authorized Individual
responsible corporate officer that owns or operates the construction activity,
* IMPORTANT NOTE: This form must be signed by a res p
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part iv,Section f3,
Item(6)of the NCG010000 permit.