NCC191812_NOI Signed Certification_20190916

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NC\G01 Notice of Intent (N01) Certification Form
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6 th Floor
1612 Mail Service Center
AMMAXOMMUM
or certification in any application, record, report, plan, or other documentfiled 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 aftne not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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
[� The information submitted inthis W0is, 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.
Va#0�K#ta i--
|vxi||abidebva||conditionoofthe NQG010000 General Permit and the approved Erosion and
Sediment Control Plan.
Ifthe approved Erosion and Sediment Control Plan isnot compliant with Part |\( PONDon
Prevention Plan) nfthe NCGO10000 General P rnit ( will nonetheless ensure that all conditions of
Part i|ofthe permit are met onthe project atall times.
| hereby request coverage under the and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asanindividual permit.
Name ofProject:
Legally Responsible Organizational Entity:
Legally Responsible Person: Y, A-
. « \�
Signature: Date: 119119
IMPORTANT NOTE.- Thisform 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 IV, Section B, Item (6) of the NCGO10000 permit.