NCC221361_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20240925

NCGO1 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed,or if the ownership of the project has changed, do NOT use this form."
Instead,you must submit a new NCG01 electronic Notice of Intent(eNOI).
Directions:
Print this form,complete,scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then,mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.Salisbury Street,6 1h Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage(COC) Number: NCC221361
Name of Project: Secrest Commons-Tract 2
Legally Responsible Organizational Entity: Forestar(USA) Real Estate Group, INC
PREVIOUS Legally Responsible Individual: Robert Price
NEW Legally Responsible Individual: Caleb Saruse
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6B(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).
Page 1 of 2

N����� Legally ���K�����^��K� U��^��^����U ������� Form
- -- - --«�--v Responsible--- Individual'— - Change
FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT [40 CFR122.221
Under penalty of law, I certify that(check all boxes to indicate your agreement):
19 1 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.
�
n�
c� | will abide 6y all conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
�
1K If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)ufthe NCGO10000 General Permit |will nonetheless ensure that all conditions of
Part || of the permit are met on the project at all times.
u� I 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.
U� This form has been reviewed and is accurate and complete to the best of my knowledge.
�
Print Name of Signed: Ca|ebSaruse
Title: Director of Land Development
Mailing Add 1412U8a||antyne Corporate Place,Suite22G Charlotte, N[2O277
Street Address: 1412OBa||antyne Corporate Place,Suite 225'Charlotte, NCZD277
Email Address. Ca|[e-mail]
Phone Number: 336-D7O-O439
IMPORTANT NOTE: Thisform must be signed by a responsible corporate officer that owns or operates the
construction activity,such as a president,secretary, treasurer, or vice president,or a manager that is
authorized/n accordance with Part IV,Section 8, Item(6)of the NCGO100Upermit.
For more information nn signatory requirements,see Part IV,Section/l Item(6)of the 0LIJ1000Opermit.
Page 2ofl