NCC193329_NOI Signed Certification_20200117

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO I.
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, 6` Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
D❑ NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E (i), any person who knowingly makes arty false statement representation,
or certification in any application, record, report pion, or other document filed or required to be maintained
under this Article or a rule impiementing this Article .. - shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under enalty of law, I certify that (check all boxes to indicate your agreement);
1 airy 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
I 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
I directly responsible for gathering the information.
7 1 will abide by afI conditions of the NCG010000 General Permit and the approved Erasion and
Sediment Control Plan -
If the approved Erosion and Sediment Control Plan is not compliant with Part Il (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit l will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times_
I hereby request coverage under the NCG010000 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 as an individual permit.
Name of Project. E VD l \) -'�
Legally Responsible Organizational Entity'
Legally Responsible Person:
Title of Legally Responsible
'Signature:
`Print Name and Title of Signed ifAuthar' ed
Individual Differs from Permittee:
Phone Number: 3 36 •
a L�
L_C_
Date: 1 ) �'!
IMPORTAAIT (VOTE: This form 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 in accordance with Port IV, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.