HomeMy WebLinkAboutNCC192173_NOI Signed Certification_20191015N CG01 Notice of Intent (NOI) Certification Form
Olredjuns
Prinoth is Form, complete, scan antl uploatl to the electronic NOI-
TM1¢n, mail tM1e original form to the NC OEM LR Stormwat¢r Program (witM1 $100 cM1edc ijpoyin9 by chec/c) at:
Division of Energy, Mineral ffi Land Resources $[ormwater Program
512 N- Salisbury Street, 6°^ Floor (Office 640K)
1612 Mdll Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEW EO ANO ACCE PTEU AS COMPLETE
Pcr NC Gencro/ 52ratute 143-215-66 (f), qny person who KngWJng/y mghes any fo/se stnfem¢n4 r¢Pr¢sen tqt/one
certificotion in pny opp/icption� r ord reporq p/gn, o other documentJJ/ed nr regviied to be moiniolned
under this Antic/e or o ru/e /mp/ement/ng th/s ArNc/¢ . sho// b¢ gut/ty f q Ooss 2 misdem¢ono� which moy
Inc/ude pT•ne not to exceed ten thpusond do//ors ($10 OOOJ.
U ntler�naalty of law, I certify that (check all boxes to Intlicat¢ your agreement):
dd I m ibe person responsible for the construe[ton activities of this project, for satisfying tM1e
requirements of this pemniq and for any dull or criminal penalties incurred due to ylola2lons of [his
I perm h.
�/ The information subm Rted In tM1is NOI is, tb tM1e best of my Knowledge and belief, [rue, a rate, and
mple2e based o my inquiry of the person or persons wM1p manage 2M1e system, or iM1ose persons
dior¢c[ly responsible for gathering tM1e information.n¢
I will abltle by all conditions of tM1e NCGO10000 G¢ ral PermK and the approv¢tl Erosion and
Sediment Control Plan.
If the approved Erosion antl Setllmen2 Control Plan is noY c mplla nt wltM1 Part 11 ($tormwater Pgll utlon
Prevention Plan) of the NCG010000 Ge ral Permit 1 will nonetheless ensure that all condi[lons. of
Part II pf the permit are met on tM1e project at a112imes.
1 hereby request coverage under the NCGO10000 G¢ ral Permit antl und¢rstantl [M1at coverage under
this perm ii will c nstltute the permit roqulremenis for TM1e discha rge(s) and is en£o rceabl¢ in the
same manner as an indlyltlual permit.
Name ofPmlec[: COD/f'/s Rom(./!+'•"r—Pv.�'...zl S/s,H�(u z e.�rr�
Legally Responsible Orga nizaiio al Entity: 1�/�/� /L� y/- � �_I" _
Legally Responsible Person: ry
Tltl¢ pf Legally Responsible -�- - l%P a i(sc i�j' � w ...�z„i
$i �' � / /
Print Nam¢ and Title of Signed if Authorized
/ndividuo/O/� rsf om Permit tee:
P M1one Number ly/p� ]_QA � llnD
� /MPORTANT NOTE: This form must be s/gn¢d by q r¢sponsib/e curporpt¢ �/cer thgf owns qr opera tes the
nstructipn pc[iWty such os o pres/dent s retgry ttegsurep p e pres/dent, o gngger tho[ is
authorized in pccprdgnce w/[h Port /V Section B I[Cm (6J pf the NCG010000 perm/fo m
For more i �rmptipn pn signptory r¢qu/rem¢nts� 5¢¢ POR /V Scctipn B� /tem (6f of the NCG010000 p¢rmlt-