NCC223561_NOI Signed Certification_20221019

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mail t
NCGO1Notice44 of Intent (NC)!} Cert'vf*cat"
ion for
Directions0
:
Print this form, complete, scan and upload to the electronic NO�.
he original farm to the NC DEMLR Stormwater Program (with $100 chec�C if paying by check) at:
v Division of Energy, Mineral _
512 N. Salisbury Street., 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699.4612
& Land Resources Stormwater Progrm
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE$,----------------------
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Per NC General Statute 143-215-6B
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makes any false statemo
tion in any opplication, record,, report, plan, or other aocumentfuea or required ro
Article or a rule implementing this Arb"cle..... shall be guilty ol a Class 2 misdemeanor whit
exceed ten thousand dollars ($10,000)d
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Under penalty of law, I certify that (check all boxes to indicate your agreement).:
structi
n I am the person responsible for the con
on activities of this protect, for satis. ying the requirements of Ihis
i
t, representation , or
e maintained under this
may include a fine not to
penaltiesincurrepermit, and for any civil ar criminald due to violations of this permit.
(� The information submitted in this N01 is., to the best of mv knowledge and belief,true,, accurate, and complete
S who manage the system, or those p rsons directly responsible for
based on my inquiry of the person o
gathering the informat*ion.
X [ will abide by all conditions of the NCG010000 General Permit and the approved
Plan,.
r person
rosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
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.
Project Name (must match Ala). Express Tire University Parkway
Specific Lot Numbers (must motch Alb): L0001 E BL2048; L0006A BL2048
ermittee mustmatchBl 8 APH Hold'ngs, LC
egally Responsible Person (must match 82 & B3). Ga oworka
Title of Legally Responsi Person (ry�ii st match B3b)* Secretaly/Tt'eaSut'ef
Name & Title of Sign
Differs from LeeWIV,
Phone Number`
f Authorwi d Indi idual
sponsibl e rso .
6-377 690 11111111, L01111111
J01111111111111
,. • i ,,,,., 1.,/0 ihlo Dcrcnn nr A"thnr17inrl Inflivid"ni Date
any person who knowini I
.
ignaLu��c�vi �c6aiwy Nv��a�...�c ��.J.,. ��.........�....,......,.....�.,.
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* IMPORTANT NOTE: Thisform must be signed by a responsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in ac ordance with Part IV, Section B,,
Item (6) of the NCG010000 permit.