NCC193226_NOI Signed Certification_20191218

NCG01 Notice of Intent (NOI) Certification Form
Print thisfc rtra, complete, scan end upload to, the eldctronic Nit�l.
Then, mail th6 original form to the NC DEMLR Stormwater Program (with $ 00 check if peying� 6y cherk) at'
Division of Energy, Mineral &'Land Resources>Stormwater Program
k2 N. Salisbury Street, 0 Floor (Office 640K)
1612 Mail Service Center
Raldlih, NC ZA991612
00 NOT MAIL THIS; FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
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Per NC General Statute 143 21 X66 (+,i, any parson who knowingly makes ony false stoteffient, rgpresentatlon,
6r certl}7catlon; rn any rppllcdtton, record; repi�rt, pion, diotIor ddeumeiit filed car requlrer� to 6 itietn#alne+
under this;4rti'cle or a rule Implementing this Article f .shall be gufttp.of olvss rrtlsdeottor which may
Include a,flne not to exceed ten thousand dollars O1t O, W),
finder penalty of law, l certify "that.(N k all boxes to indicate your air, 10 t)
0 l ahi the per on respdnsible for the construction a tivitiesoft his protect, far satisfying the
requirements cif thjt pertt�It, and for any civil or criminal penalties incurred duet , violations of this
permit.
lO The infortna�tion submitted in this Nat Is, to the hestcif tray kno.Wledge and beli+ef,`true, accurate, and
complete based on my Inquiry of' the person or persons who manage the system, or those persons
directly respoh�sible fer gathering the lnformation,
ta I will abide by all conditions of the NOCittral permit and the approved "erosion and
$edimdnt Crsntrol. Plan.
50 iftheapproved Erosion and Sediment Control Plan is n6tcompliant with Part II iStormvvater pollution
Prevention plan}''6f the WG010006 6eneral Pen»it, I will hoh0thel6s.efi ate that ill conditions of
Part Il of'the permit are ret;on the project t ail times,
I Hereby request coverage under the NC3010 00 enerel Permit and ut�daestarid that coverage under
this permit will constitute the permit re'gdirements for the discharge(s) 'and: is e,nf0rceabj0Ah the
sarf►e manner as an individual permit.
Name Of.: Project:4, 41ie Ab d r4,r try
. Phone NUmhir: 110 — 1-7 Ll _"" YZ
* IMPORTANTNOTE. This -form Must be slghgd oy o responsible corporate officer that owns or operates:the
e004 otlon activlty, such as a president, secretary, treasurer, or vice prasldent, yr a rrianager that is
r�utharized in accord anee w,it i. Part lV ectlora �, h6m (6) of the NC00 6000 permit,
For. more information on signatory requirements, see Part IV Section 6; Item (e) oi'the NC 0101000 permit.