NCC243091_NOI Signed Certification_20241016

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 6120 check if paying by check)
at:
Division of Energy, Mineral& Land Resources Stormwater Program
S12 N.Salisbury Street,6- Floor(Office 640K)
1612 Malt Service Center
Raleigh, NC 27699-1612
THE FORM YOU MAiL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.221
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 (S10,000).
Under pena'ty of law, I certify that(check all boxes to indicate your agreement):
ID I am the person responsible for the construction activities of this project, for satisfying the requirernenls of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
El 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.
ID I will abide by all conditions of the tNCUG_0000 General Permit and the approved Erosion and Sediment Control
Plan.
p✓ If the approved Lrosion and Sediment Control Plan is not comp`iant with Part II (Stormwater Pollution
Prevention Plan) of the N0001O0O0 General Permit,I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
0✓ i hereby request coverage under the NCG010000 General Pe-fmit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s)and is enforceable it the same manner as an
individual permit.
Project Name (must match Ala): Mountain Shore Mini-Storage
Specific Lot Numbers (must match Alb):
Permittee (must match Ill): Mountain Shore Properties, LLC.
Legally Responsible Person (must match B2& 63): Charles McConkey
Title of Legally Responsible Person (must match 63b : President
Print Name&Title of Signed if Authorized
:ndividual Differs from LegaI`y Responsible Person:
Phone Number: 336-880-8764
L / 1 z
Si, rature of Legally Responsible Person or Au• riled Individual U to
IMPORTANT NOTE: This form must be signed by o responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice pr cidrnt,or a manager that is authorized in accordance with Port IV,Section I3,
item (6)of the NCG010000 permit.

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Prin;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, 6-'' 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 122.221
Per NC General Statute 143-215.GB(i), any person who knowingly makes any fake statement, representation,or
certification in any application, record, report, plan, or other doc✓ment 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'avi, I certify that(check all boxes to indicate your 12{1 am the person responsible for the construction activities of this project,for satisfying the requirements of this
emit, and for any c-MI or criminal penalties incurred due to violations of this permit.
he information submitted in this NOI is,to the best of my knowledge and belief, true, accurate, and complete
ia
Te
based on my inquiry of the person or persons who manage the system,or those persons directly responsible for
lathering the information_
I will abide by all conditions of the NCG01O000 Genera. Permit and the approved Erosion and Sediment Control
Plan.
iIf the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCGO1000O 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 NCGO;0000 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:;lo}_ !kt J} i--` 1' 1c Pa. I 7S!1 6t=
Specific Lot Numbers (must match Alb):
Permittee (must match 81): �G c� OT -/ i'-.) 1f `2Y
�� t . - L
Legally Responsible Person (must match B2& 83): q4-r cZ c_ A Cc � __
Title of legally Responsible Person (must match 53b): '( 12 .i C .i
Print Name R Title of Signed if Authorized
Individual Differs`ram Legally Responsible Person:
Phone Number: 5 Ic c"*�� - 4-7 64
0.--P.--/--A---
____ (0 i Co 1.2q:
Signature of Legally Responsible Person or Au: rized individual Date
' IMPORTANT NOTE This form must be signed by resaons 't,corporate officer that owns or operates thr construction activity,
such as a vroiderit,secretory, treasurer, or vice president or a manager that is authorized in accordance with Part IV, Section B.
item(6)of the NCG010000 permit.