NCC216479_NOI Signed Certification_20211118

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NIC 01 Notice of Intent JN01) Certification Form '
Oirectiom.
Print thss fo-m, camplete, scar: and upload to t" electronic N01.
Than, rsiaifthe crigrrsal ForriiTothe NC DEMLli 5torrnwater program [witfi SIM chi ckifpayingbycheck) at:
OiAzlon of Efiergv, FAlneral K Lan dRt SourceNStormwaterPfogram
512 N. 5aIishury Street, b' Ftoor (Office 640KI
lrzi? Mz:4 Set ice (.enter
Raleigh, NC2760-9-1612
DO NOT MAIL THIS FORM OR PIAYl1AEW UNTIL YOUR AIMUCATION HAS BEEN ACCEPTED A5 COMP .ETE,
TH1E FOFtM TM MAIL MOST BE COMKMO W"M AN OFk1C I1111L SIGM UM (MM OMWAL) [40 CFR 121.2�t �
Jeer I+1i: General Sritu re 143-215.6E fi). ony person who kaowirTpfiy makes any 4representa!r1orr, or
cerrrficadorr in aeiy appflcorion, record, report, plate, €3r v ther documen t f Ed or regwred to be maintained under rhis
Article or a rux2 irnpiern enting this Article shu1fi be ga lty at 0 Vass 2 misdemeonor w hirb may include a fine not to
exceed ten thousunu UoPa-* i $10 000).
Under penalty of Eavw. I certify+ that (check all bOXes to indicate +dour agreement).
l2 1 am the persan tasponsibla for the constructtarr activi;iegr of this project, TOr satIslyfng thU Tesiuirernents of this
permit. and For amY civil of iximinal penaltiesc Pncu r m6 due W vioTafioris of thls 13ermit-
The iftfofrriat;an submItmd in this N01 is. tv the bust of my knowledge and bell of, truer amufalz-. F.nd rem plete
based on my inqu]ry of the person or persons who manage ti'm system, or those persons d frectly re5ponsib le far
eatheringtha rnforrnation.
?/1 I will ahldEf Jay all conditions of the WbDIOOM General Pgrfpg arnd the approved Eras9an and Sediment Control
Phan,
' i// if, ihe approved Erosion and Sediment Control Plan is -not ccamphant with Part It (St❑rfl ater Pollu:Pon
Peeventin n Plan} of the NCSW 10000 General Permit. I will na^_etheless ensure that aJJ conditions of Par: II of the
4 permit are rnet on the prole ct st ali tirrFes.
L� I hereby request Cmeer:ege under -Via NGGE1IDOW General Permit and and sand that €overage under this
pe;tiron-will tonstitute the permit requirements for the d&harge(s) ail Is. eniorte�' bie to the same maliner as an
Ind1vidol permit.
Name of Project (must match Ala)
Specipc t.ot Numbers (muxr mafrh Alb): Plop _
LtLgal!y Responsible OrganluOuMaI Entity (must ?notch 0J) � j�i�- K0 5 _CA WIrIi UVI
Legally Fie=nslble Person (must match B2 & A31).
Title of Legally RespanMbsle Person must match 83b)-
Naive & Title of Signed. if Authorized Individual
DJMrs front Legally ResponssibI
FhCne Ni mbpr- {
2.
Signature of Ltelafly fkespanslbla Parson or Authorized Jndividuai
Date
* BWP RTAiYTNME., Thfs fomr must be signet# bya resparr$1b& corevratr affcer rtmt vwtrs of operates the curostruWaa activity,
such os o pre#ideas recrrte+y, twmeer, or urre pre-VdPar. Ur i) rnorr,a pr thn r fs ourbar ized irr acsordnrtce whh Peat IV, Sedan B,
term (6) of the Nccioloo 4Jpe mit