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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