NCC214872_NOI Signed Certification_20210827

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
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, 6;h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
00 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLJCATION HAS BEEN ACCEPTED AS COMPLI Te.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [4E1 CFR 122.221
Per NC General5tatute 143-215.6B (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):
Li' 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.
W 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
ga hering the information.
t will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
/Plan.
I,� If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
li;hereby request coverage under the NCG0100Q0 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.
Name of Project (must match Ala):- ,
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Specific Lot Numbers (must match Alb):,,
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Legally Responsible Organizational Entity (must match B1),'' Ot , r . r'
Legally Responsible Person (must match B2 & B3):
Title of Legally Responsible Person (must match B3b):
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
PhoneF j { _ _ ,
of Legally Responsible Person or Authorized Individual
Z
Date
IMPORTAIiiT 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 1V, Section 8,
Item (6) of the NCG010000 permit.