NCC242862_NOI Signed Certification_20240920

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, cornp/ete scan and upload tn the e� 0ctron�cN
Then, n�ai/the ori��na�form to the NCDE��LRStormwater Program (vv�h $12O check
' /f paying 6vcheck)
at:
Division of Energy, Mineral & Land Resources StonmwaterProgram
S12N. Salisbury Street, Gm Floor(Office G4OK\
l612 Mail Service Center
Raleigh, NC27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) i40 CFR122'22l
Per NCGenerm/Sbrtute243-225.680lonypeoon who knowingly nno�esonyf�bestotpr�en� repnesenbz�o/� nr
oe/b�ca�on/nonyopp�cobbn, oeconirepor� p/on' orotherdo^'� �fV�d '��
, mmen mreq��d�bamo���edynder�b
Arb��oro rule inp/en�ent/ngthis Ar�c6e. . . `o0 !ego�tynfo6\o�2''�-�� wh/chnvoy/n�/udeo�nenotto
exceed ten thousand do800 ($2LlD00). ^ - Misdemeanor '
Under penalty of law, / certify that (check all boxes to indicate your agreement):
[�] | am the person responsible for the construction activities of this project,for sat/sfvin8the requirements of this
permit, and for any civil or criminal penalties incuneddue to violations nf this permit.
The information submitted in this N{]| is,to the best ofrny knowledge and belief,true accurate and complete
based onmy inquiry of the person orpeoonsvxhornana8e the system,or those persons directly responsible for
gathering the information.
I will abide by all conditions of the NCGO10000 General Pert-nit and the approved Erosion and Sediment Control
Plan.
if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
/ Prevention Plan) |m/iUnonetheless '
' ' enxuve�haLa|| conditionsofPart |{ ofthe
permit are met onthe project at all times.
O�permit
/ nereoyrequestcuvera8eundertheN[6O1O8O0Genera| Permitandunderstandthatcoverageunder1his
vvi|| constitutethepermitmequirementsforthediochar8e/o) andisenforceab|einthesamemannerasan
individual permit.
' '
Project Name (must match A1a): 1022 BnoOkbeOry Farm
Specific Lot Numbers (must nnu�h�1b\� 1���
_ ' �
Permittee (must match 6O): K4itChco, IOC
Legally Responsible Person (must match 82@ B3): Geoffrey Mitchell
Title of Legally Responsible Person (must match B3b): President
Print Name &Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number: 336-983-4362
Signature of Legally espon6|b|e Person or Authorized Individual '
Date
* IM908TA8/TKkDTE., Thisform must be signed by a responsible corporate officer that owns or operates the construction activity,
such oso president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV,section B,
Item(6)pf the WCG010000permit.