NCC214327_NOI Signed Certification_20210804

7/27/2021
Resume Submission
NORTH CAROLINA
Environmental Quality
Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) application for coverage under North Carolina's
General Permit NCGO10000: STORMWATER DISCHARGES associated with construction activities (or
NCG250000)
A. Project Information I B. Permittee Information C. Site Contact information D. E&5C Plan
E. Certification
North Carolina General Statute 143-215.6B (i) provides that:
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; or who knowingly makes a false statement of
a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate
any recording or monitoring device or method required to be operated or maintained under this Article or rules of the Commission
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:
* Q 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.
* Q 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.
* Q 1 will abide by all conditions of the NCGO10000 General Permit and the
approved Erosion and Sediment Control Plan,
* Q If the Erosion and Sediment Control Plan approved by the delegated program
is not compliant with Part Il (Stormwater Pollution Prevention Plan) of the
NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
* Q 1 hereby request coverage under the NCGO10000 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.
https:lledocs.deq.nc.gov/Forfns/formlresume/241/141530 10

7/27/2021 Resume Submission
Specify if you are: * * The Legally Responsible Person named on this Notice of Intent
Q Authorized Responsible Person* (signing on behalf of Legally Responsible
Person named in Part B)
Important: The person who electronically signs this Certification above must be the same person who signs the NO]
Certification Form. If that person is signing on behalf of the Permittee, that individual must be an authorized
responsible person within the same organization as the Permittee. *An authorized individual is a responsible corporate
officer who 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 NCG010000 General Permit. For
more information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature*
Type Name*
Title *
Organization*
Date *
Previous
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[� lle"�lf [ill
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Jacob J palillo
VP
Legally Responsible Entity
South Creek Construction Inc
Date captured on form submission
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