NCC212290_NOI Signed Certification_20210416

NCG01 Noticef InrtffiUn Form
Dir ctin s;
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, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO N T TWAIL THIS R OR PAYMENT
UNTILYOUR APPLICAT16N HAS BEEN RFWWFn ANDACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E (1), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other documentfiled 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 penalty of law,1 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
permit, and for any civil or criminal penalties incurred due to violations of this permit.
® The information submitted in this NO! 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.
X I will abide by all conditions of the KG�€ 10000 Ge eruI Per-mit and the approved Erosion and Sediment Control
Plan.
N if the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the KGO1L00-0-G -nerjj erLp t, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
hereby request coverage under the C�6010 0 c3engra� P' rWt 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): Union County Emergency Services Complex
Specific Lot Numbers (must match Alb): N/A
Legally Responsible Organizational Entity (must match 81), Union County
Legally Responsible Person (must match B2 & B3): Gordon Vincent
Title of Legally Responsible Person (must match 83b): Facilities Project Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 704-296-4252
L6 611 IO
or Authorized Individual 7 Efate
IMPORTANT NOTE. TIRI&P41must 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.