NCC230600_NOI Signed Certification_20230308

Directions:
Print this form, complete, scan and upload to the electronic N0L
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, K4)neru| & Land ResuurcesStormwater Program
512N.Salisbury Street, 6~Floor (Office 64OK)
161ZMail Service Center
Raleigh, NC27699'1G1Z
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
Per N[General Statute 143-22I68(i)any person who knowingly makes onyfalse statement, representation, 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 ... sholl be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($2(l000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
[71 \amthe person responsible for the construction activities ofthis project, for satisfying the requirements nfthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
[/l The information subnoit�/dinthis ND)i�tothe best ofmyknovv>edQeand beUetaccurate, and -- based on my inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information,
Fv(� | will abide byall conditions ofthe and the approved Erosion and Sediment Control
[7l (fthe approved Erosion and 5edinnentControl Plan isnot cnnnp|iartvvkhPart U�tnrnnwaUcrPoUut�n
Prevention Plan) ofthe } will nonetheless that all condhionsofPart Uofthe
permit are met onthe project atall times.
| 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): Eagle Point Golf Club Par 3 Renovation
Specific Lot Numbers (must match Alb): N/A
Permittne (must match 81): Eagle Point Golf Club, Inc.
Legally Responsible Person (must match B2 & B3): Robert Long, Jr.
Title of LeRallv Responsible Person (must match B3b): President
Name & Title ofSigned ifAuthorized Individual
Di�es�omLeRaUYResponsible Person:
N/A
�
Phone Numbec10-686-4653
-/?f ��
Signature of Legally Responsible Person or Authorized individual
* IMPORTAN IVOlE: This form must besigned byoresponsible corporate officer that owns moperates the construction activity,
such osopresident, secretary, treasurer, orvice president, oromanager that isauthorized /naccordance with Port IV, Section f,
Item (6)ofthe N[GO 0000perm/t.