NCC193032_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20211203

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST RE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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.
t I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
I 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.
] This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature:
Print Name of Signed: Mitch J. Ritschel
Title: Vice President
Mailing Address: 5790 Fleet St. Suite 300 Carlsbad, CA 92008
Street Address: 5790 Fleet St. Suite 300 Carlsbad, CA 92008
Email Address: Mitch. RitschelCa)kiscosl.com
Phone Number: 760-804-7066
Date: 12/01 /2021
* IMPORTANT NOTE: 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 Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
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NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCGo1 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage (COC) Number: NCC193032
Name of Project: The Pilot at Sedgefield - Water and Sewer Improvements
Legally Responsible Organizational E
KSL Sedgefield Pilot, LLC
PREVIOUS Legally Responsible Individual: Craig Taylor
NEW Legally Responsible Individual: Mitch J. Ritschel
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E (i), 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 ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
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North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources
Stormwater Program
NPDES Construction Stormwater Permit
INVOICE
Annual Permit Fee
This Construction Stormwater annual fee is required by the North Carolina Administrative Code 143-
215.D(a). The fee covers the administrative costs associated with your permit. The fee is required of
any person holding a permit for any time during the annual fee period, regardless of the facility's
operating status. Failure to pay the fee by the due date will subject the permit to revocation.
Operating without a valid permit is a violation and is subject to a $10,000 per day fine. If the permit is
revoked and you later decide a permit is needed, you must reapply, with the understanding the permit
request may be denied due to changes in environmental, regulatory, or modeling conditions.
Invoice No: NCC1.93032-2021 invoice Date: 12/1/2021
Certificate of Coverage No.: NCC193032 Due Date. 1/1/2022
Effective Date: 12/10/2019 Annual Fee Period: Dec 2021 to Dec 2022
Project Name: The Pilot at Sedgefield -
Water and Sewer Improvements
Annual Fee: S100
Legally Responsible Person: E-mail: Craig.Taylor(ca)kiscoslxom
Craig Taylor
Telephone: [phone]
KSL Sedgefield Pilot, LLC Site Contact: Craig Taylor
235 North Edgeworth Street Site Contact E-mail:
Greensboro, NC Craig. Taylor(i&iscosl.com
27401-2217
Electronic payment option is preferred. Type htt s: d_eg.nc,gov/SW-epayments into your browser, If
you select eCheck, there is no convenience fee. The convenience fee for a credit card is 2.65% and
convenience fee for debit card is $3.9S.
If you must pay with paper check, please make your check payable to "DEMLR Stormwater Program"
and include the Certificate of Coverage No. in the memo field along with a copy of this invoice.
A $25.00 processing fee will be charged for returned check in accordance with North Carolina General
Statute 25-3-512. Contact Aziza Selkane at [e-mail] or (919) 707-371D with questions.
Remit to: NCDEQ— Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh NC 27699-1612
If this project has been closed out, you must submit a Notice of Termination (NOT) request here:
https edocs.deg,ncgov Forms(NCG01-Termination