NCC243116_NOI Signed Certification_20241009

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOI.
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
512 N. Salisbury Street,6th Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute 143-215.68(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).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
❑✓ I 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.
p✓ The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate,and complete
based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
❑✓ I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
Q✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
�✓ I hereby request coverage under the NCG010000 General Permit and 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.
Project Name (must match A1a): S. Upright Street Basin Sanitary Sewer Rehabilitation
Specific Lot Numbers(must match A1b): See attached list
Permittee (must match B1): Town of Landis
Legally Responsible Person (must match 82& 83): Michael Ambrose
Title of Legally Responsible Person (must match 83b): Town Manager
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 704-857-24 1
re f Le al nsi le Person or Authorized Individual Dat
* 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.

S. Upright Street Basin Sewer Rehabilitation
Easements
TOTAL
Map Parcel
Designation Long PIN NAME1 Acreage
El 5615-12-96-0446 Carolina Builders of Cabarrus, Inc. 0.23
E2 5616-12-96-1308 Mary Jo & Gerald Agner 0.11
E3 5615-12-96-1374 Spark Ventures LLC 0.11
E4 5615-12-96-2237 Spark Ventures LLC 0.28
E5 5615-12-96-0319 Mary Jo & Gerald Agner 0.23
E6 5615-12-96-0216 Ruby Land Investment, LLC 0.26
E7 5615-12-96-1243 Ronald G. &Shelia S. Riddle 0.45
E8 5615-16-94-4918 Mike Wallace Racing, Inc. 25.75
E9 5615-16-94-4918 Mike Wallace Racing, Inc. 25.75
El 5615-16-94-4918 Mike Wallace Racing, Inc. 25.75
El 1 5615-12-95-2919 Bent Oaks LLC 0.17
E12 5615-12-95-1992 Tamera Shinn Smith 0.20
E13 5615-12-95-1886 David B. Middleton 0.22
E14 5615-12-95-1779 Carolyn &Jeff Miller 0.25
E15 5615-12-95-1763 Thomas McConnell Family LLC 0.21
E16 5615-12-95-1667 Kannapolis Properties, LLC 0.22
E17 5615-12-95-1651 Bill C. & Faye H. Eller 0.21
E18 5615-12-95-1555 Marshall D. and Katie B. Sells 0.21
E19 5615-12-95-5837 WV,LLC 1.94
E20 E. Mill Street(R/W Open) 0.00
E21 5625-09-17-3036 Michael Maganaflores 0.46
E22 5625-09-17-4100 Matthew Ryan Wallace 0.23
E23 5625-09-17-4134 Samanthat J. White 0.23
E24 5625-09-17-5159 Tosca Marie Ford 0.70