NCC221679_NOI Signed Certification_20220501

NC 01 Notice of Intent (NOI J Certification Parrn
Directions-.
Prins this Form, ccm04�tc, scan arkd LFPload to the Plectronic N01-
T'ryen, mall th10 original farm tr) the NC r)EMIR 5tnrmwater ProRran, fwiih $100chuck IfI70YOng by check) at-
Divrsipn of Energy, Mineral & Land RPSOUrCef, 5tofmwater Program
5I� N. Salisbtiry Street, G� Floor IOff ce 640K)
1612 Mail Service Center
Raleigh, NC 27699 3 63 2
DO NOT MAIL THOS FORM OS PAYMENT UNTIL YOOR APPLICATION HAS BEEN.ACCEPTE0 A5 COMPLETr'.
T141 FOItNf YOU I4hcUL MUST 'BE C13MPUTE01r1 MI AN ORfGil NAI_ SIG NATLIRE (NOT DIGITAL) [40 uit Z22:22]
Per NC C�Crrerai,Sratrjte 14.3-215-68 f+1, any persarr who knDwingiy makes any frlise Storem en1, representotion, or
tertiffcotivr? in Rny oPPlica#ion, record, report, poor, or oth[r da merrf filed ar required to be r7raintgrned under this
Article rule irr�Plcmerf#s this Article ... sl�ai!br= 9" yof a Class.2 misder?eanor which mayintlude a fine not to
exceed ten ter: thousand dollars ($30,L'O0).
Under penalty of law, I certify that (check Dill boxes to indicate your agreement):
21 f am the person responsible for the consiruc-009) ac-0vities of this project, for satisfying the requirements of this
Permit, and for arty civil or criminal penafkies incurred due t4 violations of this permit.
The info rwatfon submO-ed in th!,, NOr is, to the hest of my knowledge and belief, true. accurate, and complete
based on mar inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information-
1 will abide by all conditions of the N LGOi10000 `eneraI Permit and the approvecF Erosion and Sediment Contr❑I
Plan-
Q �f the appfo,red Erosion arrd 5edirnent Control Plan is not co}�liant with Part II �Storrrawater PoJluziorf
Prevention Plan) of the NCG01U000 Gen raf Permit. I will nonethefess ensure that all conditions of Part II of the
permit are met on the project at all tirnes-
I hereby request cowerag2 under the NCG0100Q0 CieneraJ Permit and understand that toverage under this
PermitwiiI constitute the permit requirements for the discharges} and is enforceable in the same manner as ark
individual permit,
fkroiect tame (rr?ust match Ala): Hwy 73 Flex Buildings
Specific Lot Numbers .(mui-r match A I h): — -- —
Permittee jrnusl rematch gly JCK Properties I1c,
Legarly Resporlsible Person (must OW 52 & 83). J i M M y Pre SSI oy
Itle of legally Responsible Person (mvst-rraotch 83b): Vice President
Wattle & Title of Signed if Authorized frtdivfdual
Differs from Lega[Jy Responsible Person:
Pt,one Number: 704- 01-542
Signature of LegaNy Respan5ible Person or Authorized Jndividual —
F
Date
* 1MP0 'TA?VThi0rC: This farm must be 5igried by a responsible carPdrate affic7er thor owns Or, operates the Cnrrstructiorf activity,
svch as a President, S ecretvey, tfM urFr, or vice president, or a rpanager rf?ot 6 aUthorUed in ocrol-dance. with Po r# iv, See trot? g,
l iem (6 j o f roe "C6010000 permir-