NCC210653_NOI Signed Certification_20210217

CG01 Notice of intent (N01) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMUR 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 lvi� TH15 FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E (1), any person ho 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 enalty of law, I certify that (check all boxe
Yam the person responsible for the constr
permit, and for any civil or criminal penalt
The information submitted in this NOI is, t
based on my inquiry of the person or pers
gathering the information.
C/ I will abide by all conditions of the NCG711
Plan.
to indicate your agreement):
-tion activities of this project, for satisfying the requirements of this
s incurred due to violations of this permit.
the best of my knowledge and belief, true, accurate, and complete
is who manage the system, or those persons directly responsible for
and the approved Erosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
revention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the NCG0'10000 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 (must match Ala)
�l'` T
Legally Responsible Organizational Entity (must match 1)
A--"i t. Ot5c.i. Z"'Ji -
Legally Responsible Person (must match B214 B3)
Title of Legally Responsible Per (must match Bab)
*Signature
Date
*Print Name and Title of Signed if Authorized Individual Differs from Legally Responsible Person
Phone Nu
* 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 (5) of the
i
NCGO10000 permit.