NCC231459_NOI Signed Certification_20230515

NCGO1 Notice of Intent(NOI)Certification Form
Print this form,complete,scan and upload to the electronic NOI.
Then,mail the original form to the NC DEMIR Stormwater Program(with$100 check paying by check)aT.
Division of Energy,Mineral&land Resources Stormwater Program
SU N.Salisbury Street,6"Floor(Office 66010
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 wmi AN ORIGINAL SIGNATURE(NOT DIGITAL)LAD D.122.22)
Per NC General Rotate I0.1-115.69(I),one person who blonde*makes one false statement,representation,or
certification in one oppllcotnry record,report,plan,or other document Fled or required t°be mainlined under Ns
Article ono rule implementing this Article...shallto guilty ofo Coe 1 misdemeanorwhits may include ofIne exceed ten thousand dollars($10,,000). not to
Under
penalty of law,)certify that(check all bores telndirateLions agreement):
VI I am the person responsible for the constoiction activities of Mis project,for satisfying the requirements of this
permit,
m,andfor any civil or criminal penalties incurred due to violations of this permit.
VI
The information submitted In this NOl 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,of those persons directly responsible for
gathering
he Information.
12/I will abide by all conditions of the NCG01O000 General Permit and the approved Erosion and Sediment Control
Plan.
1 If the approved Erosion aM Sediment Control Plan Is not compliant with Part II(Stormwater Polio/ion
Prevention Plan)of the DP6010000 General Permit,I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
0'I hereby request coverage under the NCG010000 General Permit and understand that coverage under.
nemn will constitute the permit requirements for Me discharges)and is enforceable in the same manner as an
individual permit.
ale.name(m2nmara7n2e): �N�II M<..clpv I/i,lw Q,
Specific lot Numbers(must match Alb): (Z
Perm0tee(martmmrh Bl): Shclo Lana
l r5 I>,,,
Legally Responsible Person(mustma..62&63): S��wt I pr'xi.
Title of Legally Responsible Person(must motel/B36): gcy-e J 14'
me.Title of Signed iltuthorixetl Individual
Differs ham Legally gesponslbM Person:
Phase xnmberreuS 1 L-129
Signa Cu IIY Responsi le lion or Authorized mdivmnal
Date
•
nIVORTItere KIM mdfon°muse be sinner,Oa remann.carp°fare officer Mat awns or goer..Me canna. .an*,
sun,as a
Ben,(6)of rp cedntano00 rvpermicsurer,w pendent endent or a manager that is auModzed to accordance with Part ion union B,