NCC233674_NOI Signed Certification_20231213

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Dr.nt thin fnrm rnm.Into rr-in ,nr4 I rnlnnri H+thn t+lnrtrnnir Mrll
Then, mail the original form to the NC DEMLR Stormwater Program (with $120 check if paying by check)
at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.Salisbury Street,61°Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
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 false statement, representation, or
certification in onv application, record. report. plan. or other document filed or reauired 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):
n 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.
0 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-71 .. _. . _
IL 1 I Will oulue by d111.UI 1U U V U 111U11� I Li IC IVI, iUUUU llCI iel di rei U 111 aI 1U die appl uveU El UJIUII dill;.)CUII I ICI IL LUilti Ul
Plan.
[l 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.
U 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): Emberglow Outdoor Resort RV Expansion
Specific Lot Numbers(must match Alb): N/A
Permittee(must match B1): Lake Lure Campground LLC
Legally Responsible Person(must match 82& B3): Frank Reed
Title of Legally Responsible Person (must match B3b): Keglsterd Agent
Print Name&Title of Signed if Authorized
Individual Differs from Legally Responsible Person: Timothy Murphy, Owner/ Partner
Phone Number: 704-249-8381
12/4/23
Signature of Le ly Responsible Per n or Authorized Individual Date
* IMPORTANT NOTE: This form must be signed bi a responsible corporate officer that owns or operates the construction activity,
such as a president. secretary, treasurer.or vice oresident,or a manaaer that is authorized in accordance with Port IV,Section B,
Item(6)of the NCG010000 permit.