NCC214935_NOI Signed Certification_20210830

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print0fisform, cornpW. scary 31W ups to tine e
Then, snail the original ern to the NC DEMLR Stormwater Program (with $100 check ifi y*V by check) at:
Vision of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 611, Floor (Office C 01
1.812 Mail. Service Center
Raleigh, INC 2769--112
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute -143-215.60 N, any Person who knowiraly makes any false statement, representation, or
Certification in any aapplication, record report, dart, or other d cur_oent filed or required to be maintained under this
Article or as rule irroier-ne sting this Article... shalt be guilt-yo a Class misdemeanor which may inclut e a fine not to
exceed tent thousand dollars ($10, ).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
L� 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.
R" 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.
M" I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
C+r( If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
I hereby request coverage under the NCG010000 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 matchAla): H J%YSS R6 S 1 Is 6 N (.E
Specific Lot Numbers (mustm atchAlb): H(C4NLAW b 1:0415ST LOT 6
Legally Responsible Organizational Entity (must match 61): J O N A T HM4 H A Y G t
Legally Responsible Person (must match B2 & B3): JOWATHA nQ H AYE S
Title of Legally Responsible Person (must match B3b): 0 WA/ 16A
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 91 -3 soy 1 8 g 6 q
Legally Responsible Person or Authorized Individual
g j2�-jto`tt
Date
* IMPORTANTNOTE. OTE. 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.