NCC215100_NOI Signed Certification_20210910

Directions:
Print this form, complete, scan and upload to the electronic N0.
Then, mail the original form to the NC DEMLR 3tormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StornnxvoterProgram
S12N.Salisbury Street, GmFloor (Office G40K\
1612Mail Service Center
Raleigh, NC27G99'l612
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification /nany application, record, report, plan, orother docu/nontfiledorrequired tobemaintained under this
Article mrorule implementingthis Article ... shall boguilty ofoClass 2misdemeanor which may include ofine not hz
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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J�r |amthe person responsible for the construction activities ofthis project, for satisfying the requirements ofthis
permit, and for any civil urcriminal penalties incurred due toviolations ufthis permit.
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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
gathering the inforrnation.
| will abide byall conditions ofthe NCG010000 General Permit and the approved Erosion and Sediment Control
ow� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit, Iwill nonetheless ensure that all conditions ofPart ||ofthe
permit are met onthe project atall times.
|h�re6vrequeytCovenageunderthe un
derstand -'
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): "gf&vvk�e'A AQ k b 1 6y-"k
LA 9 FA
efeas
Specific Lot Numbers (must match Alb): "xkb�
Legally Responsible Organizational Entity (must match Bl):
Legally Responsible Person (must match B2 & B3):
Title of Legally Responsible Person (must match B3b):
Name & Title ofSigned ifAuthorized Individual
Differs from |
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Phone Number: �� ��� ~ ����-�'—
Signature of Legally Responsible Person orAuthorized Individual Date
*�ORTANTNOTE.- This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such osopresident, secretary, treasurer, nrvice president, oromanager that isauthorized /naccordance with Part IV, Section 4