NCC210183_NOI Signed Certification_20210112

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
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, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETr
Per NC General Statute 143-215.6B (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 ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Und;17m
alty of law, I certify that (check all boxes to indicate your agreement):
the person responsible for the construction activities of this project, for satisfying the requirements of this
Zermit, and for any civil or criminal penalties 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
athering the information.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
�/�Ian.
L� If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the °, I will nonetheless ensure that all conditions of Part II of the
�/�ermit are met on the project at all times.
Ltd I hereby request coverage under the NCGO10000_General Per 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.
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Name of Project (must match Ala
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Legally Responsibl Organizati
0 I G'At Ulm
it En ity (must match B1)
Legally ResponsibI4 Person (must match B2 & B3)
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Title ofiRaly Respon ' le rso must math B3b)
*Signatures Date
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*Print Nam and Title of Signed if Authorized Individual Differs from Legally Rfsponsible Person
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Phone Number
* IMPORTANT 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 B,
Item (6) of the NCGO10000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of the
NCGO10000 permit.