NCC242921_NOI Signed Certification_20241009

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��. C'G �.'. t,k: ofntent (NOI) IC e Ufic Lion Form x
Directions:
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Print this form, complete,scan and upload to the electronic NOI.
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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 I
512 N. Salisbury Street, 6th Floor(Office 640K) I
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1612 Mail Service Center 1
Raleigh, NC 27699-1612 J
THETOW.VOU MAILmUSUBE COMP. ll i AL-SI NATURE 0401l OIGIT li) t3 EII t.22,22j I
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Per NC General Statute 143-215.6E(i), any person who knowingly makes any false statement, representation, or 1
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). t
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Under penalty of law, I certify that(check all boxes to indicate your agreement):
0 I am the person responsible for the construction activities of this project,for satisfying the requirements of this I
permit, and for any civil or criminal penalties incurred due to violations of this permit.
0 The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate, and complete
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based on my inquiry of the person or persons who manage the system,or those persons directly responsible for :!
gathering the information.
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byapproved Erosion and Sediment Control ,
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i will abide all conditions of the NCG010000 GeneralPermit and the
Plan.
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0 If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCC,O1000C?General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
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Q✓ I hereby request coverage under the €NCGO1OCJOO General Permit and understand that coverage under this I
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an
individual permit.
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Project Name (must match Ala): Performance Precast
Specific Lot Numbers(must match Alb): n/a
Permittee(must match B1): RNH Incorporated
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Legally Responsible Person(must match B2& B3): Randy Humphrey {
Title of Legally Responsible Person (must match B3b): President
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Print Name&Title of Signed if Authorized II
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Individual Differs from Legally Responsible Person: ii
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Phone umber: 7048958015 1
/ i ' ,77.- --- ,,
Sig ure ofleg Responsible Person or Authorized Individual Date
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* IMPORTANT NOTE: This form 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 in accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.
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