NCC243396_NOI Signed Certification_20241112

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete scan and upload to the electronic N0L
Then' mail the original form to the N[DEMLRStonnvvaterProgram (with $12O check V"paying by check)
at:
Division of Energy, Mineral& Land Resources StnrmwaterProgram
512N. Salisbury Street, 6* Floor(Office 640K)
161J Mail Service Center
Raleigh, N[2769y'lGll
.
T�� F�R�� y40[FR122.22\
Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement, representation, or
ce/ltificorion /nonyopp/icotion, recond, report, pb/n, urotherdncunnentfilpdorrequiredtnbenno/nto/nedunderthis
�rt��/eo,oru/e�np/ennen�ngth�A��/e. . .shall begu8tyo/o [�ss2/n�denneunur which nnoyinclude uftnenot to
exceed ten thousand dollars ($1(IO00).
Undzrpena!tyof|uw, | xertifythat (checkaUboxestoindicateyoura0reemnent):
^
�/( I am the person responsible for the construction activities of this project, for satisfying the requirements of 4'his
permit, and for any civil or criminal penalties incurred due to violations of this permit.
[� The information submitted in this NOI is,to the best of my knowledge and belief,true, accurate, and comp|eta
based on my inquiry of the person or persons who manage the system, or those persons directly res.ponsible for
gatheringthe information.
c 1 ,will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sedirnein't
Plan.
^ ^ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part H of the
permit are met on the project at all times.
[7 herebyi-equest coverage under the NCGO10000 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 A2o): Anson Gas Producers FlNG Pipeline Project
�
"-oechic Lot Numbers (must match A2b):
. Permictee (must match 82): A�lSnD Gas pnOdUDeFs. LLC
LeQa||y Responsible Person (must match fQ@B3): VVil|i@rO Brinker
Title of (mu��«notch8�h)� Director vfp,|m|anuoevco.uc.Sole Member o,Anson Gas pmuuoem.�Lc
Print Name&Title of Signed if Authorized
individual Differs from Legally Responsible Person:
Phone Number: 864-567-9950
Signature of Legally Responsible Person or Authorized Individual " �ate
* 144PQRr4NTNODE: This form must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president,secretor^ treasurer,or vice president, or a manager that is authorized in accordance with Part IV,Section B,
/r­m (6)o/the NCG020000permit.