NCC222668_NOI Signed Certification_20220725

NCGO1 Notice of Intent (NOI) Certification Farm
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if poyinG by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED As COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122,22]
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, repres?ntation, 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 mfsdPmennnr which may inrf jdp n fine not to
exceed ten thousand dollars ($10,000).
Under penally of Idw, I certify that (check all boxes to indicate your agreement):
❑r 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.
0 The information submitted in this N01 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_
❑� 1 will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
Q If the approved Erosion and Sediment Control Plan is not compliant with Part li (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,
✓Q I hereby request coverage under the NCG010000 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.
Name (must match Ala),Summit Medical Office Building
Soecific Lot Numbers (must match A1bl: 225545
Permittee (must match 81): PP MOB III, LLG
Legally Responsible Person (must match 82 & 83): Joe P. Pearson
Title of Legally Responsible Person (must match B3b)_ Manager
Namc & Title of 3%iicd if AULliui iced Individual
Differs from Legally Responsible Person:
Phone Number: 704-867-5002
A Q-�L " --
gna ure of Legally Responsible Person or Authorized Individual )ate
5r
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the Instruction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance wirh Pan IV, Section 8,
item (6) of the NCGO10000 permit_