NCC216452_NOI Signed Certification_20211118

NCGm1 Notice of Intent (NOI) Certification Form
Directions:
Print this form„ complete, sera and upload to the electronic N®I.
Then, mail the original form to the NC DEMLlt Stormmrrater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormaauater Program
512 N. Salisbury Street„ fim Fbor (Office e640K)
1612 Mail Service Center
Raleigh, NIC 27699-1612
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 122.221
Per NC General Statute 143-215.58 fi), any person Who knowingly m ukes arny olse statement, representation, or
certification in any application, record, report plan„ or other docummrernt fulled or required to be maintained under this
Article or a rule implementing this Article ... sha#J be a3uifty ofa C'llbss.2 misdemeanor which moy include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of lava, I certify that (check all boxes to indicate your agreement) -
Ed I am the person responsible for the construction actiivaies of this project,, for satisfying the requirements of this
permit, and for any civil or criminal penalties incurred due to violations of this permit -
Ed The information submitted in this N01 is, to the best of m y/ 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.
i will abide by all conditions of the NCG'010000 General Permit and the approved Erosion and Sediment Control
Plan.
E if the approved Erosion .and Sediment Control Plan is not compliant with Part 11(Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, l will nonetheless ensure that all conditions of Part II of the
/ permit are met on the project at all times.
2 1 hereby request coverage under the NCG01'0000 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). UNOX Expansion
Specific Lot Numbers (mustmatchAlb). 4603202911, 03201390
Legally Responsible Organizational Entity (must match BA. UNOX Inc
Legally Responsible Person (must motch B.2 & B3): Ma* WindeTa
Title of Legally Responsible Person (must retch 0b): President
N ame & Title of Signed if Authorized Individual
Differs from Legally Responsible Persona,
Phone Number. [phone]
:r
/t I zvzo
Zffl
reof Legally Res nsible Person or Authorized 11ndNiduall Date
IMPORTANT NOTE: This foam must be Signed by a respornsiblle corporate of x' ,,r that owns or operates the construction activity,
such as a president secretary, treasurer, or vIke presoent are accordance with Part IV, Section B,
Item (6) of the NCGO10DOO permit.