NCC221470_NOI Signed Certification_20220414

NCOO1 Notice of intent (NOI) Certification Form
Directions-.
Print This form, complete, scan and upload to the elec,ronuc NO',
Then, mail the ariginal form to the NC DEMLR 5tormwaier Program (with $100 check if paying by check) at.
Division of Energy, Mirt2ra19 Land Resources Stormwater Program
512 N 5ailisbury Street, &, Floor (Office 640K)
1611 Mail Service Center
Raleigh. NC 17699-16L2
DO NOT MAIL TH15 FORM OR PAYMENT UNTIL YOUR APPUCATiON HA5 BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST M CUMPLETED WfTH AN ORIGINAL 51GNAIURiE {NOT DIGITAL) (40 CUR 122.221
Per NC General Sraturt 143-215.6E (i), any person who knowingly makes any false statement. reprs-sentorion, or
rernfrcarion in any applirzition, retard report clan, or other dacumPrsr filed or required to he maintained under this
Article or c ru=e implementing Phis Articie , . , shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars f$10,0001,
tinder penalty of law, I cenrify that jcheck ,41 boxes to Indicate your agreement):
© I am the person responsible for the construction act 1viites of this pra;eat, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred dui; to vialatrons of th,5 permit..
Q The Iniormation submitted in this NGI i., 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 respomible for
gathering the information.
0 I will abide by all conditions at The f►ks4i[]UClf? Ci#=1lra} f'erri'ut and the approved f rtysron and Sediment Contra!
Plan
Q If the approved Erfton and Sediment Control Plan is not compliant with Part Ii (Stormwater Pollution
Prevention Planj of the NC6010000 Ge eU I PerrTiq I will nonetheless ensure that all coniditions of Par. 11 ofrhe
permit are rr1P-t an the pra*rf of ail times.
0 I hereby request coverage under the NC 1000U Gcrzeral Pf rmat and unae-mtand that cvverago under this
permit will consrttute the permit requirementsfor the discharge(sl and is enforceable in the same manner as an
indviduai permit.
Project Name (must match A2a}: South Sityland Drive
Specific Lot Numbers (mast match AM: 1.2,3,4
Pernnittee Imusi match 91): J2 Land invesimets
Legally Responsible Person (must match B2 & E3): John Lambert
Title of Legally Responsible Person {must match 83by: Chief of OpteratlonS
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person: Ttla
Phone Number. 704-453-2700
416J 2
It_ure of4je:ga,1N Responsible Person or Authorized individual--
Elate
IMPONTANT NOTF: rhrs form mu0 tee signed by a responsible corporare officer thin owns of aprrares the construction activity,
such ai o president, ierrnwy, rremurer, or vxe president at a niariager that is ourhanzed in accordance wire? Part IV, Section B,
stem 16) of the AtCG0104?0i7 permlr.