NCC243594_NOI Signed Certification_20241120

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NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form,complete, scan and upload to the electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with$120 check if paying by check)
at:
Division ot Energy, Mineral & Land Resources StormwaterProgram
512N.Salisbury Street, 6^ Floor(Office 64OK)
161Z Mail Service Center
Raleigh, N[27699'161Z
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Per N[General Statute 143-215.6B(i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record,report,plan, or other documentfiled 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/$1[\00[V.
Under penalty of law,I certify that(check all boxes to indicate your agreement):
F71 I am the person responsible for the construction activities of this project,for satisfying the requirements ofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
F71 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.
[7l I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
F,1 If the approved Erosion and Sediment Control Plan is not compliant with Part U (Stormvvate/ Pollution
Prevention Plan)of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
�� I hereby request 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 A1o): HODO82 Suites by Hi|b}D
Specific Lot Numbers (must match A26): Lot 10
Permittee (must match 82): PDG Greenville, LLC
Legally Responsible Person (must match B2@BJ): Bi JU Patel '
Title nf Legally Responsible Person (must match B3b : Manager
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 336-2
TF
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� Signature of Legal es ipn�ible Person or Authorized IndividualDate
~ 0NpORTAN7NDTE: Th ƒosigned byo responsible corporate officer that owns ur operates theconstroctionoctivity,
such oso president,secretary, trecou er, ur vice president, u,o manager that is authorized in accordance with Part IV,SectionB,
Item(Vof the wDG0z000Opermit.