HomeMy WebLinkAboutNCC212758_NOI Signed Certification_20210510NCG01 Notice of Intent (N01) Certification Form
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, 61h Floor (Off -ice 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.6E (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 penalty 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 permit, and for any civil or criminal penalties incurred due to violations of this
permit.
Ill The information submitted in this ivoi 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.
50 1 will abide by all conditions of the N'C6010000 General rertni1. and the approved Erosion and
Sediment Control Plan.
X If the approved Erosion and Sediment Control Plan is not compliant with Part If (Stormwater Pollution
Prevention Plan) of the i ;_G€ i0000 General Parrni' I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
X I hereby request coverage under the fJCGQ QQ0Q Niteroi Pen-rii 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: 10th Regimental HQ (P-1509)
Legally Responsible Organizational Entity: MCB Camp Lejeune
Legally Responsible Person: Neal Paul
Title of Legally Responsible Person: De a Public Works Officer
ature:
*Print Name and Title of Signed if 4hthorized
Individual Differs from Permittee: Talia Prendergast, PWD Civil Engineer
Phone Number: (910) 451-3238 ext. 3242
Date:
* 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 8, Item (6) of the NCGO10000 permit.