NCC192092_NOI Signed Certification_20191001

NCGO1 Notice of Intent (NO8) Certification Form
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 StommwaterProgram
512N.Salisbury Street, 6mFloor (Office 640K)
1612 Mail Service Center
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Sta/ute143-215.6B (I), any person who knowingly makes any false statement, representation,
orcertification /nany application, record, report, plan, orother documrntf0edorrequired tobemaintained
under this Article ororule implementing this Article ... shall 6eguilty qfoClass 2misdemeanor which may
include ofine not toexceed ten thousand dollars ($2(lOOD).
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
permit.
The information submitted in this NOI 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.
| will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
|fthe approved Erosion and Sediment Control Plan isnot compliant with Part|| (StormvvaterPo||ution
Prevention Plan) nfthe NCGO10000 General Permit | will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project atall times.
| 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 asanindividual permit.
Legally Responsible Organizational Entity: e.A— 4AJ//-//< .5- y
Name of Project:
Title
of Legally
*Print Name and Title a igned if A,�rized
Phone Number:
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the
construction activity, such as apresident, secretary, treasurer, or vice president, mromanager that is
authorized in accordance with Port IV, Section 8, Item (6) of the NCGO1 0000 permit.
For more information on signatory requirements, see Part IV, Section B,/tem (6) of the NCG010000 permit.