HomeMy WebLinkAboutNCC211468_NOI Signed Certification_20210312NCGOZ Notice of Intent (NQI) Certification Form
Directions:
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, 6t^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
D❑ NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Stature 143-215.68 (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):
m 1 am the person responsible far 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.
m The information submitted in this NO[ 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.
® 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
m If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
m 1 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.
Name of Project (must match Al a): Circle K - NTI Holly Ridge NC.111
Specific Lot Numbers (must match Alb): Not Applicable
Legally Responsible Organizational Entity (must match B1): Circle K Stores, Inc
Legally Responsible Person (must match B2 & B3): Meredith W. Rice, Jr.
Title of Legally Responsible Person (must match B3b): Vice President
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person: Not Applicable
Phone Number: (919) 774-6700
Signature of LegaIly Res ponsi W Person or Authorized Individual Date
IMPORTANT NOTE: This farm 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 1V, Section 8,
Item (6) of the NCG010000 permit.