NCC242373_NOI Signed Certification_20240813

NCGO1 Notice of Intent (NO1) Certification Form
Chrectsons
Print this tam.con+plete, scan and upload to the eiect'onk NOt
Theft,m 4 tlse original loan to the NC D(MLA Slarnwater Program(with$120 caack (paying Pr theta)
st.
DMsiort of ('w y.Mineral$ Land Resources Sto►mwater Program
512 N.Sa5tbtrr Street„6•floor(Office 6400
1612 Mall Service Center
ltalegfl,NC 27699-1612
TM FOAM YOU MAIL MUST OE COMPUTE 0 WIN AN ORIGINAL SIGNATURE(NOT 016STAL1140 C * 12212)
Pet NC General/Statute 143-215 68(a), onepersor wrto tnowMrtpry motes any foie storrewnr, representation.or
certification An ony oppAcodon, record, report plan,a otter document pet a required to be ntoestnned wider/Art
Artrcte or o nee impternenting this Article sAof at emery of o Opts I rnudern donor whet stay include a fine not to
e•r eed ten ffo.,sa+e donors 1$3O 0)
Under penalty of law,i trinity that(check all bosun to heist@ your apoomeM)
I am the pennon retponstbie for the conuVvcton atiet tees of this protect,fat satWstprtg the repu►rerttents of thn
permit,and for art,avd or minimal persalpti ncurred due to violations of this permit
Q The mfamatlon admitted in this$01 Is, to the best of my kr+ow+edae and betel, true, accurate, and complete
based on my inquiry of the person or persons who mantra the system. or those genets chrectly responsible for
Eatherirg the 1rtiorrnation
Cl Iwo abide by all conditions of t e tN1CG011)Q0O Geist►try and the approved(ration and Sedvnernt Control
Plan
Q 11 the approved Erosion and Sediment Control Nan Is not comp/ant with►a•t a(Storm-water eoautlom
Prevention Kan)of the tranGtellfigogrifirzad, I will nonetheless ressioe that M conditions of Pat n of the
pe►rnat are mot or the protect at as troves
Q.r I P b, request coverage under the Q142QQ GerwtA„Nmat and understand that coveters under this
permit watt constitute the permit requirements for W e dbcherpts)and h entorcesble in the Same manner a1 an
andlestimat pin mitt
►slit/Nance (mint matan Alai Expront Gas Station Conversance Slurs
_Speak tot leurribers(neat match Ajb
Pernrtue(must match t1}: Praru, LLC
taiat'Y Resfions+ele Person j nr„t m*ea*V a iJ : Praahant Paled
Tine al �1 r st!s¢orssi le Person ynasr Owv*r
Print Name&Title of Signed it Authorised
Yt+Mdrel Others from Laiai Retponstle Parton
Phone Number -721-425e
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iytlealr. AetooaMie Msos or AMhortsed Individual 011ie
• WPM TAW NOTt ram teem matt t+e wp+ee Iv a eviempeeare revs a tie r911Cirr We was a Ma+roas t4 ranaorwtoon amorp,
Ise ea•/Rs+M*t.serApierf rlstalour.a/sat//nnMsat;is•~wee,cline N dime llwf av«sara nt.we*Airy N, %mean j
Iris NI e/04 lorG0100120 peer.[