NCC191516_NOI Signed Certification_20190823

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Print this form, complete, scan, and upload to the electronic NOL
Then, mail the originail form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61"1 Floor
1612 Mail Service Center
Raleigh, NC 276,99-1612
Per NC General Stotute 143-215.6B (i), any person who knowingly makes any folse 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. . . sholl be guilty of a Class 2 misdemeanor which may
include affne not to exceed ten thousand dollars ($10,000).
(Jn�'iur rxnaPty of k@,,M1, fi ceri3fy that all boxes to irrdicate Your
I ffie person n.?sPonsible fm the consltrucl*on a (.J,' M ties of Uiis prniect, ior sahsfyin�,, tho
M.JUirerlif'ants of lhipermt, am.] for,'.my OW (,,,r c, Ylnjnal Hof: naltiec.', Iricurrclj ducl.o of this'
er
e fr) I'm ""� b on s u b rn i t tee in t h i,s N 0 1 �!';' t <:r t I a e b e S t of ray. kno w I edge d.s n (.J I u e f, l, ru e, a r ate, fi
compic"te 1[')dscA on lily iw"�t'Ofy of the Person or perscjrv@ who rn,.imgethe systc?m,. per,�owL
dh,coy r(..',,spcmslhkr, for gathcrring the jnforrll,�fl-ion,
wd! abide by conditions of the the! apvm osk, ni3r-�rJ -wed Er: rind
control Plan.
lf the approved [lf.)son and Sedrnent Contro� Man is nal cornpUarit'�,vith Part H (Starmwater PpHtMc'o
f)rcvenbon PiC"'n) of the 'T' ;' � � � ' ,
WW th;lt ZlH C,0116"Jons of
Pat H M Ole permit 'nre niet on th(a prof, (A at all i m es
i herc'by cc"Ver'ag�" Under the th;,A tmdk-bp
thkE mnt will constituw thc,,. permit requk-(']n'lent's Ior the and ls kn the
S„I;Mjl an rndMduai
Name of Project: N
Legally Responsible Organizational Entity: SLA Proerty, LLQ
* Legally Responsible Person: Nathan BaltS
Title of Legally Res sib�ll,e Person. Manager
Signature:
7 CIL Date:
*IMPORTANTNOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Port IV, Section, B, Item (6) of the NCG01000,0 permit.
For more information on signatory requirements, see Port IV, Section 8, Item (6) of the NCGO10000 permit.