NCC222694_NOI Signed Certification_20220726

('--ert:sfica'b , n Form
Print this form, complete, scan and upload to the electronic NOI.
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, 6o, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO 1�JGT r-iV-11L THIS y' •- R A z+LICATIGN HAS PEEN ACCEPTED AS COMPLETE.
THE FOr�t4`f YOU MAIL fYtl i5 3 ! ::iJ:r:3_ i {'r'I-i idl C1tz GINAL SIGN ATtJ€ E (NOT DIGITAL) [40 CFR 122.221
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report plot), or other document filed or required to be maintained under this
Article or a rule implemen tiny this Article .. , shrill be guilty of a Class 2 rnisdemeonor which may include a fine not to
exceed ten thousand dollars ($10,000),
0rider penalty of law, I certify th,3t (ch e. !< <il; haxES co indicate your agreement):
[]J I am the person responsible io; it1 .. L 0:t, •.r;:, t nn aiiwities of this project, for satisfying the requirements of this
permit, and for any civil or c.ritt o,,i; IBC r;t:l ie - incurred dur to violations of this permit.
[J The information submitted in tt,is 1101 is ,o , he best of my knowledge and belief, true, accurate, and complete
based on my inquiry of the pers, )n or persons who manatml
ge the system, or those persons directly responsible For
gathering the information.
❑J I will abide by all conditions of the a ! . r=r << and the approved Erosion and Sediment Control
Plan.
❑ If the approved Erosion and ler,irnent C.t,,atr=,1 Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the : ' I will nonetheless ensure that all conditions of Part II of the
permit are met on the pfDJOc :..� :.0
❑J € hereby request coverage undt r the _'. _.._ e,.-.! € rr rmit and understand that coverage under this
permit will constitute the perm,k requiremei;ts for the discharges) and is enforceable in the same manner as an
individual permit.
Project Name (mustmatchAlo):NHMMC Bed Tower Expansion
Specific Lot Numbers (must match Alb):
Perm ittee (must match Br): Novant Health, Inc.
Legally Responsible Person (must match 82 & [33): Matthew Stiene
Title of Legally Responsible Person (must match 83b): Senior VP, Construction and Facility Services
Name & Title of Signed if Authorized individual
Differs from Legally Responsible Person:
Phone Number: 764-316-4351
-)dJ -T —7~���
Signature of Legally Responsible Person or Authorized Individual Date
* 1MPORTANTNOTE. This form must be signed by a responsible corporate officer that owns a operates the construction activity,
such as a president, secretory, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section 8,
Item (6) of the NCG010000 permit.