NCC214175_NOI Signed Certification_20210719

NCG41 Notice of Intent (N01) Certification Form
Directions-
Print this form,complete,scan and upload to the electronic NOI.
Then,mall the original form to the NC DEMLR Stormwater Program (with$100 checkif pay#nq by check)at:
Division of Energy,Mineral& Land Resources Stormwater Program
512 N.Salisbury Street,61,Floor(Office 640If)
1612 Mail Service Center
Raleigh,NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS DOMPLETE.
THE FORM YOU MAIL MUST RE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL)140 CFIt 122.221
Per NC Generof Statute 143215.68(lf,any person+who k►rotWngly makes any false statement, representation, or
certification in any application, record,report,plant,or other document flied or required to he maintained under this
Article or a rule implementing this Article. ..shall be guilty of a Glass 2 misdemeanor which may ihclude a fame nat to
exceed tern thousand dollars($10,000),
Under pen aKy of law,I certify that(check all boxes to indicate your agreement),
f am the person responsible for the co nstru ct ion a ct iviti es of this p roject,fo r satisfy)ng t he req u irem ents of th is
�} permit,a nd for any civil or cri mi n all pe nalties 1 ncu rred d u e to viol atio n s of this permit.
L�J The information submitted in this NO is,to the best of my knowledge and belief, true,accurate,and complete
based on my Inquiry of the person or persons who manage the system,or those persons directly responsible for
gathering the information.
CO I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
plan.
It If the approved Erosion and Sediment Control'Plan is not compliant with Part II(Stormwater Pollution
Prevention Plan}of the N00010000 General Permnit.I wall nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
PJ I hereby request coverage under the NCG010000 Gene ral perm it and u nd ersta nd that coverage u nde r t h is
permit w ill constitute the perm it requi rements fo r th a discharge(s)and is enforceable in the s ame ma n n er as an
individual permit.
Name of Pr9ject(most match Ala): V(D L A N1 D� �l���� �� LoT2
Specific Lot Numbers(must match Alb): 2— ..11.._ ..._
Le ally Responsible Organizational Entity(rmnust match 81): VANM 66 A l�
Legal ly Respo risible Person(must match 82&83): V AN IA V0 6
Title of Legally Responsible Person(must match 83b : LAND O W N E 19FNEtAL C0 TkA -l0k
Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person;
Phone Number: 656 5.3�-5— 8914
­ : 7L16L0,0Zf
Signature of Legally Responsible Person or Authorized Individual Date
* IMPORTANT N01T. This jb rm must be Sighed by a rewnslbte carparate officer that owns or operates the canstrurerion activity,
s ach as a president secretary,treasurer,or vice president Dr o manager that is out horired in accordance with Fart W,Seaton$,
Item(6)4 the Nceo'loom permit.