NCC210235_NOI Signed Certification_20210126

NCGO1 Notice of Intent (NOU) Certification Form
Directions:
Print this form, complete, scan and upload tnthe electronic NCU.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if payingbvche[k at:
Division of Energy, Mineral /& Land Resources StormvxuterProgram
5l2N.Salisbury Street, G`^Floor (Office 648K)
1612Mail Service Center
Raleigh, NC 27699-1612
0O NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute 143-215.68(i), any person who knowinglymakes onyfolse statement, representation, or
cer��cobbn/nany opA0co�mn,necon�repo/�p/on orother docunnent��dornequ�edtohenno�tu�edunder thb
Article ororule implementing this Article ... shall baguilty ofoClass 2misdemeanor which may include ofine not bn
exceed ten thousand dollars ($10,000).
Under penalty oflaw, Icertify that (check all boxes t#indicate your :
7X I am the person responsible for the construction activities of this project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
ON The information submitted inthis N0is, tothe best ofmyknowledge 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.
X | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
91 if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions ofPart ||ofthe
permit are met unthe project ntall times.
X | 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.
Cow Mountain Road
Name of Project (must match Ala)
Chinquapin LLC
Legally Responsible Organizational Entity (must match Bl)
William Adkins
Legally Responsible Person (must match 62 & B3)
Managing Member
Title o2fgallyi)eponsible Person (must match B3b)
1/12/21
Date
*Print NamWand Title of Signed if Authorized Individual Differsfrom Legally Responsible Person
704.896.5880
Phone Number
*IMPORTAN7IVOTE. This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such usopresident, secretary, treasurer, orvice president, oromanager that isauthorized /naccordance with Port IV, Section 8,
Item (6) of the NCG010000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6)ofthe
N[6010000prnn/t