NCC201297_NOI Signed Certification_20200401

NCGO1 Notice of Intent (N41) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO1.
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, Wh Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIE YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-115.6E (ij, any person who knowingly makes ony false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be main toined
under this Article or a rule implementing this Article ... shall be guilty of a Class 1 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,OOO).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
?C 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.
X 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.
3�1 I will abide by all conditions of the ' +•:_ and the a
Sediment Control Plan,
approved Erosion and
If the approved Erosion and Sediment Control Plan is not compliant with Part ll (Stormwater Pollution
Prevention Plan) of the ', I will nonetheless ensure that all conditions of
Part Il of the permit are met on the project at all tunes.
I hereby request coverage under the '.
and understand that this permit will constitute the permit requirements for the discharge(s) and is enforceable i therage under
same manner as an individual permit.
Name of Project: i'�aRTlt
Legally Responsible Organizational Entity:�6V6 L.OI�6N r
A -gyp.
Legally Responsible Person:
Title of Legally Responsible Person:
'Signature:
'Print Name and le of signed if authorized
individual Differs from Permittee:P4 p
Phone Number: _� 9 r z 71 v
Date:
IMPUK I ANT NOTE: 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 (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, item (6) of the NCG010000 permit.