NCC232729_NOI Signed Certification_20230919

NCGO1 Notice of Intent (NOI) Certification Form
DirectionF
Print this form,complete,scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program(with $100 check if paying by check)at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.Salisbury Street, 60 Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIM.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 143-215.68(i),any person who knowingly makes any
certification in any application,record, report,plan,or other document filed or required to be maintainedtio 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):
0 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.
[✓ The 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
Plan.
Q If the approved Erosion and Sediment Control Plan is not compliant with Part iI (Stormwater Pollution
Prevention Plan)of the,vCGuiu000 General Permit I will nonetheless ensure that all conditions of Part li of the
permit are met on the project at all times.
jJ i hereby request coverage under the CG010000 General Permi~
uerstand that cverage under this
permit will constitute the permit requiremen the discharge(s)and isenforceable ina he same manner as an
individual permit.
Project Name (must match Ala): Bee Hive Farm
Specific Lot Numbers (must match Alb):
Permittee(must match B1): Bee Hive Farm LLC
Legally Responsible Person (must match B2&B3): Mark L Maynard Sr
Title of Legally Responsible Person (must match B3b): Managing Member
Print Name& Title of Signed if Authorized
Individual Differs from Legally Responsible Person:
Phone Number: 910-251-5030
Signature of Legally espon ' le Person or Authorized individual
Da e
* 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 NCGQ10000 permit.