NCC222795_NOI Signed Certification_20220825

NCGO1 Notice of Intent (N01) Certification Form
Dirt;:
Pant this form., complete, scan and upload to the electronic NCI.
Then, mail the original form to the NC D E M L R Sto r m wate r Program {with $140 check if paying by check} at:
Division of Energy, Mineral $c Lind Resources Stormwater Program
512 N. Salisbury Street', 6th Floor {office 640lf}
1612 Mail Service tenter
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 143-215.6B (i).1 ❑ny person who knowingly makes any false statement, representation., or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule implem en tin g this A rticle ... shall b e guilty of a Class 2 misdemeanor which moy include afin e 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
A�
permit, and for any civil or criminal penalties incurred due to violations of this permit.
The information submitted in this NCI is, to the best of my knowledge and belief, tree, 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.
will abide by all conditions of the NCGO10000 General hermit and the approved Erosion and Sediment Control
Plan.
If the approved Erasion and Sediment Control Plan is not compliant with Pert Il (Stormwater Pollution
Prevention Plan) of the NCGO10000 general Permit, I will nonetheless ensure that all conditions of Part it of the
permit are met on the project at all times.
hereby request coverage under the NCGO10000 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): Prose Rhyne
Specific Lot Numbers (must match Alb):
Permittee (must match Bl): Prase Rhyne Alliance, LLC
Legally Responsible Person (must mach B2 & B3): Donald Santos
Title of Legally Responsible person (must match BA).- Owner
Name 8t Title of Signed 'if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 704-728-9706
MOM tea u �
ft
idle Person or Authorized Individual
IMPORTANT NOTE Thisform must -be signed by a responsible corporate officer t o t owns or operates the construction
secretary,such as a president, r rer, or vice presI dentor a manager that is authorized in occordance withPart IV, Section 8,