NCC192613_NOI Signed Certification_20191101

NCG01 o#ice of Intent (N01) Certification Form
DI r ectiom,-
Print th€s form, complete, sran and upload to the electronic N01.
Then, mail the original form I[to the NC DEMLR Stc rinwater Program (with $100 check if paying by check)a t:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N. Salis»iry Street,61h Floor
1612 Wil Service Center
Raleigh, 1'1C 27699-1612
Per NC General statute 143-21 .68 N, any person who knowingly makes any false statement,representatioll,
or certification in any application,record,report,plug, or other document filed 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 a fine not to exceed ten thousand dollars ($5 6,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement):
1 am the person responsible for the construction activities of this project,for satisfying the
requirements of this permit, and for any ci-ii ar criminal penalties incurred due to violations of this
permit.
The information subalitted in this NOI is,to i:he hest of my knowledge and belief,true,accurate,an�€
complete based on my inquiry of the perse n or persons who manage the system,a those persons
directly responsible fir gathering the information.
I will abide by all conditions of the NCGO10)IH}General Permit and the approved Erosion and
Sediment Control Pla .
LV If the approved Erosio and Sediment Control Plan is not compliant with Part I (Storm water PDIIutI n
Prevention Plan)of the NCG010000 Generc i Permit. I will nonetheless ensure that all conditions of
Part II of the permit are met an the project at all times.
1 hereby request coverage under the NCGQ,iil000 General Perrnit and understand that coverage unq er
this permit will constitute the permit requii ernents for the discharge{s)and is enforceable in the
same manner as an individual permit.
Name of Project:
Legally Responsible Organizational Entity: S ��
Legally Responsible Person:
Title of Legally Responsible Person: Ituk
Signatur
Date:
* IMPORTANT NOTE: This form ust be signed by a re.;ponsible corporate officer that owns or operates the
construction activity,such as a�.resident,secretary, t e-asurer, or vice president, or a manager that is
authorized in accordance with Part iV,Section 0, Item 16)of the NCGO10000 permit.
For more information on signatory requirements,see Port iV,Section 8, Item (6)of the NCGO10000 permit.