NCC221835_NOI Signed Certification_20220517

NCGO1 Notice ofIntent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload tothe 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 5tonnwaterProgram
512N.Salisbury Street, G*Floor (Office 64OK)
1612Mail Service Center
Raleigh N[2769g-2G12
DO NOT MAIL THIS FORM 00PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, orother documentfiledur required tobemaintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($20, 000).
Under penalty uflaw, | certify that (check all boxes toindicate your agrammxant):
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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.
The information submitted inthis NU|is, tothe best ofrnyknowledge 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.
L�J | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
Ed 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 ofPart Uofthe
permit are met onthe project atall times.
h�| | 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 is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): AQV0Le_4<1- �UAXIIV DbNLt6r_5
ific Lot Numbers (must match
Permittee (must match 81
Legally Responsible Person (must match B2 & B3):
ICY
�e tic
-Title of Legally Responsible Person (must match B3b):
A 77
Name & Title ofSigned ifAuthorized Individual
Differs from Legally Responsible Person:
neof-tega||vResponsible Person orAuthorized Individual
3-/10/2,7-
Date
8kPORTAWVTMOTE. This form must besigned byoresponsible corporate officer that owns o/operates the construction activity,
such asopresident, secretary, treasurer, or vice president, momanager that is authorized in accordance with Part IV, Section 8,