HomeMy WebLinkAboutProposed DaVita Dialysis Center - Signature Sheets<t ( ft(aN
2e do certify that
before *" Ú,i21day of zÒt
Public for the State of /\) (:County of
personally appeared
and the due of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission I l.¿) I
l, (print or type name of person listed in Contact lnformation, iteru 1ø) lacob Hertz. . . -
ceitify that the informàtion included on this permit application form is, to thebestof my knowledge, correct and
that the project will be constructecl in conformance with the approved plans, that the required deed restrictions
and protèctive covenants will be recorded, and that the proposed project complies with the requirements of the
applicable stormwater rules under 154 NCAC 2H.1000 and any other applicable state stormwater requirements
X. APPLICANT'SCERTIFICATION
l, a Notary Public for the State of , County of
do hereby certify that personallv aopeared
-
"^*.@n of the application forbefore me this
-
day of
a stormwater permit. Witness my hand and official seal,
SEAL
My commission
Form SWU- l0 I Version Oct. 3 I , 20 I 3 Page 6 of6
Signature:
l,v
\NAS\Z, , do hereby certify rhat
before me thisffia y ot \C-hVt A
a stormwater permit. Witness my hand and official seal,
SEAL
MELISSA E.iìCLL
STATEOF
HY
a Notary Public for the st^t" ot NO&ln ( qV Á^fuounty of
"Înr¡nnas VWs{f ' personatly appearect
'?-o\*-,and the due execution of the application forq-
Date þ/?
My commission 7Æ7-O
X. APPLICANT'SCERTIFICATION
Date:
l. , a Notarv Public for the State of , Countv of
do hereby certify that personally appeared
before me this day of , _, and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
Mv commission expires
Form SWU- l0l Version Oct. 3 I, 2013 Page 6 of6
t,elJ*AN otary Public for the State of
^J
County of
do hereby that personally appeared
before methisâ( day of and acknowledge due execution of the application for
a stormwater permit. Witness my
My commission
X. APPLICANT'SCERTIFICATION
L , a Notary Public for the State of County of
- do hereby certify that personally appeared
before me this _ day of and acknowledge the due execution of the application for
a stofmwater permit. Witness my hand and official seal, _
SEAL
My commission expires
(J
SEAL
Form SWU-I0l Version Oct.3l,2013 Page 6 of6
As the legal property owner I acknowledge, understand, and agree by my signature below, that if my designated
agent (entity listed in Contact Information, item 1) dissolves their company and/or cancels or defaults on their
lease agreement, or pending sale, responsibility for compliance with the DEMLR Stormwater permit reverts back
to me, the property owner. As the property owner/ it is my responsibility to notify DEMLR immediately and
submit a completed Name/Ownership Change Form within 30 days; otherwise I will be operating a stormwater
treatment facility without a valid permit. I understand that the operation of a stormwater treatment facility
without a valid permit is a violation of NC General Statue 143-215.1and may result in appropriate enforcement
action including the assessment of civil penalties of up to $25,000 per day, pursuant to NCGS 1.43-215.6.
Signature: Date:_
I, a Notary Public for the State of County of
do herebv certifv that oersonallv anr¡eared
and
before me this _ day of , and acknowledge the due execution of the application for
a stormwater permit. Witness my hand and official seal,
SEAL
My commission
X. APPLICANT'SCERTIFICATION
L a Notary Public for the State of fnlo /c./County of
doherebycertify *at TaCab ll e¡l-z personallyappeared
before me this Zhuy of ôr ln //^ o l1.and acknow of the application for
a stormwater permit. Wihress my hand and official seal,
SEAL
K.
NOTARY PUBLIC
SÍATE OF COLORADO
NOTARY lD 201ô4040386
My commission
Form SWU-l0l Version Oct. 31,2013 Page 6 of6