NCC211595_NOI Signed Certification_20210319

NCG0l Notice of lntent (NOl) 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 5100 check if poying by checkl al:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,t' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAILTHIS FORM OR PAYMENT
UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Stotute 74j-275.68 (i), ony person who knowingly mokes any false statement, representotion, or
certification in ony opplicotion, record, report, plon, or other document filed or required to be mointoined under this
ArticleororuleimplementingthisArticle...shallbeguiltyofaClass2misdemeonorwhichmayincludeofinenotto
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
{ t u^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.
C m" 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.
V I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
V lf the approved Erosion and Sediment Control Plan is not compliant with Part ll (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part ll of the
permit are met on the project at all times,
d t hereby request coverage under the NCG010000 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.
lndependence Plaza Stalls Medical, lnc
Name of Project (must match Al-al:
Specific Lot Numbers (must motch ATbl:
Legally Responsible Organizational Entity (must motch Bl): Stalls Medical, lnc
Legally Responsible Person (must motch 82 & B3l: Jerry Stalls
Title of Legally Responsible Person (must match Bibl:
Name & Title of Signed if Authorized lndividual
Differs from Legally Responsible Person:
Phone Number: 919-41 4-3046
./,) -202)
Date
* TMPORTANT NOTE: This form must be signed by o responsible corporote officer that owns or operates the construction activity,
such os o president, secretory, treosurer, or vice president, or o manoger that is authorized in accordance with Part lV, Section B,
Item (6)of the NCG070000 permit.
Responsible Person or Authorized lndividual
President