NCC231173_NOI Signed Certification_20230428

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' CGO1 Notice of Intent (NOI) Certification Form
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Directions:
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Print this form,complete,scan and upload to the a tron3 N
Then,mail the iginal form to the NC DEMLR Stormwater Program (wi h$100 check i aying by check)at:
Division of Energy,Mineral&Land Resources Stormw erPro ram
512 N.Salisbury Street,6th Floor(Office 640K)
1612 Mail Service Center
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 143-215.6E(i),any person who knowingly makes any false 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...shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
✓gi I am the person responsible for the construction activities of this project,for satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit.
telZThe information submitted in this NOI is,to the best of my knowledge and belief,true,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.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
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Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
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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
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permit will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit. tJCi— ,
Project Name(must match Ala): Plato Lee Road Shell Building #3
Specific Lot Numbers(must match Alb):
Permittee (must match 81): SNCBHC LLC
Legally Responsible Person(must match 82& 83): Peter Rackov
Title of Legally Responsible Person(must match B3b): Chief Financial Officer
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 1 O(' 463 -5.44 OCR
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Signature of Legally Responsible Person or Authorized Individual Date
* IMPORTANT NOTE: This form 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 accordance with Part IV,Section B,
Item(6)of the NCG010000 permit.

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Invoice Description Amount Discount Net Amount
Lcii iL1..0 i GENERAL PERMIT
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No:31516 4/20/2023 NC DEMLR STORMWATER PROGRAM Amount $ 100.00
THE REVERSE SIDE OF THUS DOCUMENT INCLUDES MICROPRINTED ENDORSEMENT LINES AND ARTIFICIAL WATERMARK-HOLD AT AN ANGLE TO VIEW A
S Steffes Solutions LLC Cornerstone Bank 77_71/913 31516
P. gm STEPPES 3050 Hwy 22 North Dickinson,ND
a Dickinson, ND 58601-9413
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z Date:4/20/2023 No:31516 Amount $ *****"*****100.00
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One hundred and 00/100 USD***********************************************************************************
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Pay to the NC DEMLR STORMWATER PROGRAM Steffes Solutions LLC
Order of DIV OF ENERGY/MINERAL& LAND RESOURCES
STORMWATER PROGRAM/512 N SALISBURY ST J SEN$''
6TH FLOOR(OFFICE 640K) 1612 MAIL SVC CTR
RALEIGH NC 27699-1612 �oEsw,