NCC192741_NOI Signed Certification_20191113

NCGO1 Notice ofIntent (NOk) Certification Form
Directions:
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check ifpaying bycheck) at:
Division ofEnergy, Mineral & Land Resources 8tonmxvaterProgram
512N.Salisbury Street, 6mFloor (Office 64UK)
1612Mail Service Center
Raleigh, NC 27699-1612
TO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEE
REVIEWED AND ACCEPTED AS COMPLETE i
Per NCGeneral Statute 143-215.68(i{any person who knowingly makes onyfalse statement, representation,
or certification in any application, record, report, plan, or other document/ledmrequired to be maintained
under this Article orarule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not bnexceed ten thousand dollars ($1Ll0[K).
Under penalty oflaw, | certify that (check all boxes toindicate your oQreemneMd:
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.
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 Uofthe 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 isenforceable inthe
same manner asanindividual permit.
Name of Project: ZORTAt,1 V�6TA`-�
Legally Responsible Organizational Entity: K& Oome, R^u�,w� - VuMp%m
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Title ofLegally Reomonsib|��e�,
on: ���?��������"~� A-ArAn- 'DMkIr--l�,>
Date:
*Print Name and Title ofSigned if Authori#d
Individual
*IMPORTANT &OTE/Thisform must besigned byoresponsible corporate officer that owns oroperates the
construction activity, such asupresident, secretary, treasurer, or vice president, oromanager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information onsignatory requirements, see Part IV, Section B, Item (6)ofthe NCGO1U000permit.