NCC210188_NOI Signed Certification_20210112

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
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 COMPLETE
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).
Under of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the requirements of this
�/�ermit, and for any civil or criminal penalties incurred due to violations of this permit.
Lam ' 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.
B' 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Pan.
Woolf the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General_ Permit. I will nonetheless ensure that all conditions of Part II of the
_�ermit are met on the project at all times.
Lrf I hereby request coverage under the NCGO10000 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.
Nash County Land Clearing & Inert Debris (LCID) Landfill
Name of Project (must match Ala)
Legally Responsible Organizational Entity (must match B1)
Legally Responsible Person (must match B2 & B3)
*Print Name and Title of Signed if Xuthorized individuattiffers from Legally Responsible Person
2. - 91 --
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
NCG010000 permit.

William Hill
From: Craig Fortner <[e-mail]>
Sent: Monday, January 04, 2021 3:16 PM
To: William Hill
Cc: Steve Nichting
Subject: NOI Certification Form
Attachments: NCG01-eNOI-Certification-Form-20201222-DEM LR-SW.pdf
Follow Up Flag: Flag for follow up
Flag Status: Flagged
:.............................................................................................................-..............
CAUTION: This email originated outside of the Nash County email system.
Do not click links or open attachments unless you recognize the sender, the email address and know the
content is safe.
..........................................................................................................................................................................................................................................................................................
Mr. Hill
Happy New Year! Please find the attached certification form —this is the last administrative hurdle to clear on the LCID
erosion control plan (procedural at this point.) Please do the following with the form:
1. Check all of the boxes
2. Sign, date, print name/title, phone number
3. Scan signed form and email back tome
4. Mail original signed form to the following address:
NC DEMLR Stormwater Program
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
We will pay the admin fee of $100, Please let me know if you have any questions.
Craig M. Fortner, PE
Garrett & Moore, Inc.
206 High House Road, Suite 259
Cary, NC 27513
O: [phone]
M: [phone]