NCC200871_NOI Signed Certification_20200304

NCG01 Notice of intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload. to the electronic NOI.
Than, mail the.originaI form to the NC DEMLR Stormwater Program (with $100 check if paying by cheek) at:
Division of Energy, Mineral &Land Resources 5tormwaterProgram
512 N. Salisb.ury Street, 6" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27695-1612
DO NOT MAIL THIS FORM OR PAYMENT ANTIC YOUR APPLI CAT] ON HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute I43-2I5.68 (i), any person who knowingly makes any false statement,representation,
or certification in. any application, .record, report, plan; or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shinl be guilty of a Class 2 misdemeanor which may
include a fine not to. exceed ten thousand dollars ($10, 000).
Under penalty of €aw, I certify that (check all boxes to indicate your agreement):
l am the person responsible for the construction activities of this project,. for satisfying the
requirements of this permit, and for any civil or cdmina€ pen a€ties 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.
l will abide by all conditions of the NCGO10000 Gene ra€ Permit and the approved Erosion and
Sediment Control Plan..
If the approved Erosion and Sediment.ControI Man is not compliant with Part II {5tormwater Pollution
Prevention Plan) .of.the NCGO10000 General Permit, I 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 NCGO10000 General Permit and understand that coverage under
this permit will constitute. the permit requirements forthe discharge(s) and is enforceable in the.
same.manner as an individual permit.
Name of Project: WftTti GAkpW14& MS YAr-k4N kVCoM1,601
Lego llyResponsible: 0rganizationa€ Entity: 3WM C'QLfti.1NAc
Legally Responsible Person: Q
'title of Let=ally Responsible Person:
*.Signature:
PH nt Na me and Title 64Signed if Atgh)�rized
Individual Differs from Permittee:
Phone.Number: g •&M---
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* IMPORTANTNOTE. 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 Part IV, Section 8, Item (s) of the NCG0J 0000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.