NCC193063_NOI Signed Certification_20191206

NCG01 Notice of Intent (N I) Certification Form
_ Directions:
Pflnt this form, complete, scan and upload to the electronic NOL
Then,niait the original form to the NC 0EMLR Storrnwater ProgFarn (wuith$100 creek ff paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 611 Floor{Office 6401<}
1612 Mail Service Center
Ueigh, NC 27699-1612
i
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Fee,NC General Statute 143-215.6A (i), very person who knowingly rnokes any fafSe staterrre"t representation,
or certlficotion in any applkatron, record, report,Piper, or other documeAf filed or required to be rnvintoined
under this Article or o rule implernerrfing tM Article. . . shail be guilty of u Closs 2 nar'sdemeonor which moy
include a fine not to exceed Fen thou5ond dollars ($10,000),
Under penalty of law, R certify that (check all boxes to indicate your agFeernent):
I am the person responsible for the construction activities of this prpjeO, for satisfying the
requirements of Ihts permit, and for any cn+ii or criminal penalties incurred due to violations of thi9
permit-
31/
The information submitted in this NO 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 informat4on-
I will abide by all conditions of the KG010000 General Permit and the approved Erosion and
Sediment Control Plan.
if the approved Erosion and Sediiment Control Plan Is not cornptiar1i with Part II (Stormwoter Pollution
Prevention Plan)of the{NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part Il of the permit are met on the pro)ect at all times.
h hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this permit will tonstitute the permit requirements for the dischargels)and is enforceable in the
same manner as an individual permit,
{Name of Project; � *
Legally ltespansibie0rganixationaIEntity: i , — --
Legally ResponsiblePerson; __--
Title crf Legally Responsible Person: a140 0L— _
`Signature: fate_ IZ- -ZC"
*Print Name and Title of Signed of Aurhorl2ed
fndividuol Di fers�rvm Permltteeq ------ _
PhaneNumber gig - 11_ I - - ----Y -�
' IMPORTANT NOTE: This fvrm muse be signed by a responsible corpaiate aff-rcer fhat owns or o rates the
con'IrdePon acilvfty,such as a president, S-e retary, treasurCr, or vice president, or a manager rho is
authadMd In accordance with Pant IV, 5cction S, item (6)of the NCG010000 permit.
For Irrbre Orrfarmatlon an signatory requkemern-i,sae Part IV, Section B, Item{IS)of the NCC-010000 permit.