NCC222273_NOI Signed Certification_20220712

MGM Notice- of Intent 1) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 60, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT lti!@AIL THIS FORM OR PAYMENT UNVL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE,
THE FORM YOU MAIL MUST BE CO IPLETED WITH AN O€cl G NAL SIGNATURE (NOT DiGITAL) [40 CFR 122.221
Per NC General Statute 143-215.6E (i), any person who knowingly makes any folse 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).
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.
�✓ 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.
2 1 will abide by all conditions of the NCGOI-0000 General Permit and the approved Erosion and Sediment Control
Plan.
0 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NOG,61-0000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
[✓ i hereby request coverage under the NC60:10000 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.
Project Name (must match Ala): Clerk's Preserve Phase l
Specific Lot Numbers (must match Alb): NA
Permittee (must match 81): Southbury Development, L.L.0
Legally Responsible Person (must match B2 & 83): David Chapman
Title of Legally Responsible Person (must match B3b): Manager
Name & Title of Signed if Authorized Individual Differs from Legally "onsible Person,. NA
Phone Number:
7 4,11 & /"� J _� --)-
Signature of legally Responsible Person or Authorized Individual Date
IMPORTANT NOTE: This farm must be signed by a responsible corporate officer that awns 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 NCG010000 permit.