NCC223630_NOI Signed Certification_20221026

NCC 01 Notice of Intent JN01] Certification Form
Girectlon5!
Print this form, oarnvN te, scan and upload to the elmronir NCi-
Ph�on, nail the origlinal forma to the, NC D EMLR Starrnwater Drggram (with SNO clerk if poy�ng by cheek; at;
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6I Flopr{Office 64OK f
1612 Mall Service i�:eF)ter
Raleighr NC 276fS9-1612
a0 NO'i MAI1 L THIS FOAM OR PAYWNT UNTIL YOUR APPLd[ATION f1A5 BEEN ACCEPTED 11E OC MPILV E
7NE F011W YOU MAI L M UST BE COMPLETED WrrN AN ORFG1 NAL SiGNI TUWE (NOT DIGITAL) 1410 M 122221
Fer AfC Eerrera� Statute 143-2;5.I$ fil ony person who knowingly makes mlyfi)fw sratemenir reprvgenWi( n, or
-certJfkation )n any oppa ea6on, r e rd, report; plan, or other dvcunwat For *r regWred [o be rMontar'ned -under this
Arfi[�e Cr a ruJe implementing this .Articfe , - . s;mP be puilfy of o 7 mJsderwanor which mcry incJode a fine noT to
exceed tern tho+5arhd dogs ($10, OM).
Linder penalty of law, I certify that (check all boxes to Indicate your agreert wt):
I am the person respomible for the -constructlon actiivltles of this project, fqrsMi5fyingthe requ Irements of this
perm It, and for any avid or criMi"I penalties inamrr-ad due to violations erf this permit-
The- infefmatupn su brined In thiis NOI K W the best of my knowledge and belief, truer accu rater a nd complete
based on my inquiry of tfie- person or persnn5 w ho ma nage the system, or those persons directfyr respnnsihle for
Bath eri ng the irrl'ormation.
Q 1 wriil abicle by all conditlons of th a NC O L0000 General Pe rmit and the approved F ro5Ion a nd Sediment Control
P Ian.
® If the apprgyed E-o5ion and Sed lme-nt Cont,mi Plan is fiat oornpCank wrt}a Part II (Starn'+water poll utlon
P reventlon Ple n } of the NCGQ1 r 9 will nonethe4ess ensure that al I Conditions *f Part II of the
perm it are met on the project at all tlrrmes.
21 1 hereby request coverage under R he NCG010D00 General PErrnit and understand that r rage u-nder t!hjs
perm It will consut,ute. the permit requirements for the discharges) and Is enformble in the same mariner as an
ind iwid;wa I perm lt.
Proje<i Marne (must match AJg). The Auction House
Spectflc Lot Numbers (must march Alb}:
P.erinittee imusx match 81); M PG Upstate LLC
lepllyr Responsible Person (myst +etch &?8a i93L T. MarM Fddy
Trtle of LUallY Responsible Person (Must rrwtch R3b): Manager
Name & Title of 54n ed if Authorized I ndividu al
blffers from, Lilly Ra5pi)rF.5ible PeFScin-
Phone Nufr~ber= 864-423-3275
Signature cf Lega lly Responsible Person or Awhorized Individual e
* 11WPORTAMIr NOTE: ThLs firrrrr crust be signed DY er r'esponsrbtr cwporatr officer that awns or operates (he MnSVuEthm -octA y,
;ach a% a premient, secretory, treasurer, or vk-e presiderit, or o ff&prs M t�4rj rS awthzt+d r.q occwdaffe wRb part JV, 5ecrdon 8,
JtEM 16k of the.NCG0180W perMJf.