Loading...
HomeMy WebLinkAboutNCC220256_NOI Signed Certification_20220118NCGO1 Notice of Intent (NOI) Certification Form Directions: Print this form, complete, scan and upload to the electronic N01. 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, 6 � 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 143-215.68 (i), any person who knowingly makes ony folse statement, representation, or certification in any application, record, report, plop, or ocher documentfiled or required to be maintained under this Article or a rule implementing this Article ... shall be guilty of o Class 2 misdemeanor which may include o fine not to exceed ten thousand dollars ($10,000). Under penalty of law, I certify that (check all boxes to indicate your agreement): Q✓ 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 N01 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. �✓ 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 �► 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 permit will constitute the permit requirements for the discharge(s) and is enforceable in the same manner as an individual permit. . Northwest Thorn Bluff Specific Lot Numbers (must match Alb): N/A Per-mittee (mist rxwtch B1): Northway Hornes.LLC Legally Responsible Person (must match B2 & 83): Cyrus Mojdehi Title of_Legally Res_ponsible Pelson (mus-tmatch-B3b4:-Manager Name &Title of Signed if Authorized Individual N/A Differs from Legally Responsible Person: Phone Number: 858-354-1479 1/10/22 Signature of Legally Responsible Person or Authorized Individual Date IMPORTANT NOTE: This form muse be signed by a responsible corporate officer that owns or operates the construction activity, such as o president, secretory, treasurer,, or vice president, or o manager that is authorized in accordance with Port IV, Section B, Item (6) of the NCG010000 permit.