NCC192612_NOI Signed Certification_20191101

NCGO1 Notice ofIntent (NOU) Certificb orm
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 Stormwater Program
512 N.Salisbury Street,6t'Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIII THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS B'­­
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 243-215.68(i), any person who knowingly makes onyfnbe statement,representation,
m certification inany application, record,report,plan, mother documentfiledm required tobemaintained
under this Article morule implementing this Article. . .shall be guilty ofoClass 2 misdemeanor which may
include o fine not to exceed ten thousand dollars($1{lDDU).
Under penalty of law, \ certify that(check all boxes to indicate your aQneennent\:
8U |am the person responsible for the construction activities of this pn�ectfor sati�vinAthe
'
requirements of this permit,and for any civil or criminal penalties incurred due to violations of this
permit.
UU 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.
UU |will abide by all conditions nfthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
0U If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)ofthe NCGO10000 General Permit |will nonetheless ensure that all conditions of
Part || of the permit are met on the project at all times.
0U | 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 asan individual permit.
-Legally Responsible Organizational Entity:. es-yq ClAae-tTr Ltc
-Legally Responsible Person: - 90'J
-Title of Legally Responsible Person: I A tAN-P
*Signature: Ee-lu IFQ Date: /.a ro
*Print Name and Title of Signed if AuthoriAd
Individual Differs from Permittee:
-Phone Number:
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 inaccordance with Part IV,Section B, Item(6)of the NCG010000 permit.
For more information onsignatory requirements,see Part IV,Section B, Item(6)of the 0CGO 0000pennit.