NCC212709_NOI Signed Certification_20210505

Directions -
Print this form, complete, scan and upload tnthe electronic NOL
Then, mail the original fonntethoNCDEKHLRStormwaterPro4grem(vvith$l0Ocheck/fpoyivgbyehed/ at
DiWoionufEne,gy PWinera|&Land ResouoaoStormwate,Program
'
61ZN.Salisbury Street, 61hFloor (Office G4QK)
1612Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM ORPAYMENT
UNTIL YO
Per NC General 5totute243-21J6B(i),any person who knowingly makes anyfalse statement, o/
rarb�co�on/nany cpp n�no¢n�pm�p6�� or ohrunpen�fN�* representation,
xw'/�^ w other ^ ~or�4�e to under this
Ar�deoronz�implementing this Art��...sho0beou/�vofo[&�a2nn�denreonorvvh�hrnoyinclude ' maintained
�c�d�nthousand do�o�1���. ~
Under penaltyoflaw, | 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 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.
I will abide by all conditions of the NCG010000 General Perml-t and the approved Erosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part It (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit, | will nonetheless ensure that all conditions ofPart |lofthe
permit are met oothe project atall times.
| hereby request coverage under the 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,
tch
-,.,Name of Project (must ma Ala): > t t1*4"
Specific Lot Numbers (must match Alb): A
Legally Responsible Organizational Entity (must match B1 C'V'l
—Legally Responsible Person (must match B2 & B3):
-Title of Legally Responsible Person (must match B3b):
Name & Title nfSigned ifAuthorized Individual
Differs from
Signature of Lega�y Responsible Pe�sW—or Authorized Individual Date
�IMPORTANTNOTE: This formmust be signed bypresponsible corporate officer that owns or operates the construction activity,
such asopresident, secretary, treasurer, mvice president, mwmanager that is authorized in accordance with Part IV, Section B,
Item (6)qfthe NCG010000permit.