NCC221232_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20240815

IN CGIDI Leg lily Responsible individual Change F r,,,n
� j
Use this form when:
The person wh is legally respo isible fo the permit has changed, but there is NO CH NGE in t e project name
or ownership.
**If the projf ct name has cha iged, or if the ownership of the project has changed, do NOT usa this form.**
Instead,you nust suk mit a new NCG01 electronic Notice of Intent( NOI)'.
Directions:
Print this fo m, complete, sc in and u iload to the Construction Stormwater Permit ODIFIC TION Form.
Then, mail I he original form to the NC DEMLR Stormwater Program at:
Division of Energy Mineral&Land Resources Stormwater Progr m
512 N.Salisbury Street,61h Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOTMAIL THIS FPItM U YOUR MODIFICATION HAS BEEN REVIEWED AND S COMPLETE.
THE FO M Y M 1 Ui OMP TED WITH AN ORIGINAL SIGNATURE(NOTJCCEMEJ�
IGIT L CFR 122.22]
Certificate of CIverage (COC) Number: NCC221232
Name of Proje : Summerhav n West
Legally Respo ible Organizational Entity: DR Horton, Inc.
PREVIOUS Leg Ily Responsible Individual: less Meyer
NEW Legally Responsible individual: Nil Uldrick
The following section is to be completed and signed by the NEW Legally Responsible I divi�'uall
Per NC Genera Statute 143-215 6B(i), a y person who knowingly makes any false statement, rE presentation,
or certification 'n any applicatio , record, report,plan, or other document filed or requ red to be maintained
under this Arti le or a rule implementing this Article. . .shall be guilty of a Class 2 mis emea or which may
include a fine r at to exceed ten ffiousand dollars ($10,000).
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CG01. L ly Responsible Individual Change I'
THE FORM YO J MA U5 MPL TED WITH AN ORIGINAL SIGNATURE(NOT GITA ) � CFR 122.22]
10
Und:71
natty f la , I ertify t at(check all boxes to indicate your agreement):
am I he person responsible fo the construction activities of this project,for satisfying the
requi emerits pf this permit, a�d for any civil or criminal penalties incurred d e to viol tions of this
perm t.
I will bide by II conditions of he NCGO10000 General Permit and the approved Erosion and
Sedin ent C opn rol Plan.
Lag' If the approved Erosioi and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
PreVE ntion!Plan)of the NCG01 000 General Permit I will nonetheless ensure that all conditions of
Part l of the permit are met on the project at all times.
I undi rstan'd that coverage under this permit will constitute the permit requremerts for the
isch rge(s') and is enf:)rceable in the same manner as an individual permit.
This rm has been reviewed a id is urate and complete to the best of my know e 'e.
%6
*Signature: . 8/15/2 24
� Date.
Print Name of igned: Neil UI ric
Title: Divisioii Stormwater Co pl�ance Specialist III
Mailing Addre s: 4150 Mendenhall Oaks Pkwy, High Point, NC 27265
Street Address Same as abov
Email Address: NRUldrick@driorl:on.com
Phone Number: 3368999240
*IMPORTANT N TE. This form must be signed by a responsible corporate officer that owns or op erates the
construction a tivity,such as a presfdent,secretary, treasurer, or vice president, or a manager that is
authorized in c ccordance with Part IV,Section 8, Item (6)of the NCGO10000 permit.
For more infor, atio on signatory equrements,see Part IV,Section B, Item(6)of the,NCGQ1O f0 permit.
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