NCC212405_NOI Signed Certification_20210422

Directions:
Print this form, complete, scan and upload tothe electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)at:
Division ofEnergy, Mineral & Land Resources StormwaterProgram
S12N.Salisbury Street, 6*Floor (Office G4OK)
161%Mail Service Center
Raleigh, NC2769y-1612
DO NOT MAIL THIS FORM OR PAYMENT
Per NC General Statute143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification inany application, record, report, plan, or other documentfiled or required tobemaintained under this
Article ororule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may include aftne not to
exceed ten thousand dollars ($20,000).
Under penalty of law, |certify that (check all boxes to indicate your agreement):
X1 |amthe person responsible for the construction activities ofthis project, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit.
*J The information submitted in this NOI is, to the best of my knowledge 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.
F-J | will abide 6yall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
91 Kthe approved Erosion and Sediment Control Plan isnot compliant with Part U(StonnwmterPoUution
Prevent�nPlan) ofthe |wiUnonetheless ensure that oU ' itionuofKart||ofthe
permit are met onthe project atall times.
1Z | 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 perm|t.
N a me of Wolf Lake Road Construction
Specific 6e /5866903/4
Chinquapin, LLC
—Legally—Legally Responsible Organizational Entity (must match Bl): Will Adkins
Title of Legally Responsible Person (must match B3b): Managing
Member
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
Phone Number- 704.896.5880
Signature of Legally Responsible Person or Authorized Individual
IMPORTANrNOTE. This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that isauthorized /naccordance with Part IV, Section a,