NCC192151_NOI Signed Certification_20191007

Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form tothe NCDEK8URS1onnwate/Program (with $1U0check /fpaying bycheck) at:
Division ofEnergy, Mineral & Land Resources 3tonnwaterProgram
5l2N.Salisbury Street, 6tbFloor (Office 64OK)
161ZMail Service Center
Raleigh, NC27G99 1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute243-225.6B (i),any person who knowingly makes mnyfialsestatement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article ... shall beguilty ofoClass 2misdemeanor which may
include ofinenot toexceed ten thousand dollars /$2(\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.
'
L] The information submitted inthis NO|is, tothe best ofmyknowledge 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.
[] | will abide byall conditions ufthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
[] If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project atall times.
[] | hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and iaenforceable \nthe
same manner asanindividual permit.
BuildingsName of Project: Davis Drive -
LegallyNe Organizational Entity: ARE NC Region NC 14, LLC
allv Responsible Person: Oliver Sherril
'Print Name and Title ofSigned if Authorized
Individual
Phone Number: [phone]
*�����TE.- Thbformmust be signed byoresponsible corporate officer that owns or operates the
construction activity, such cis a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information onsignatory requirements, see Port IV, Section 4Item (6)4fthe N(IO100OOpermit.