NCG060014_Name Ownership Change Certification_20180418

Permit Name/Ownership Change
PERMITTEE Certification Signature Supplement Form
Why is this signed form needed?
Permittees and/or applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22. Until electronic submittal meets Cross -Media Electronic
Reporting (CROMERR) requirements, this signed form must either be submitted with the
application or mailed separately to:
DEMLR Stormwater Program
1612 Mail Service Center
512 North Salisbury Street
Raleigh, NC 27699-1612
[RECEIVED
PPR 18 2018
[?ENR -LAND QUALITY
"TORMWATER PERMITTING
Lid CHECK HERE IF PERMITTEE WILL MAIL IN SIGNED FORM INSTEAD.
Permit Number ACG7 OC Cao /'/
North Carolina General Statute 143-215.6 b (i) provides that:
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; or who knowingly makes a false statement of a
material fact in a rulemaking proceeding or contested case under this Article; or who falsifies,
tampers with, or knowingly renders inaccurate any recording or monitoring device or method
required to be operated or maintained under this Article or rules of the [Environmental
Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor
which may include a fine not to exceed ten thousand dollars ($10,000).
Permittee Certification (Permit holder prior to the ownership change or permit
holder authorizing name change)
I, /'/i"cA,4 e / &SA , attest that this application for a name or ownership change has
been reviewed and is accurate and complete to the best of my knowledge. I understand that if
all required parts of this application are not completed, and that if all required supporting
information is not included, s applicatio kage will be returned as incomplete.
(2 2�i8
Signature Date