NCC216821_NOI Signed Certification_20211217

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, Stan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 chink if paying by check) at:
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N Salisbury Street, 6, Floor (Office 640K)
1612 Marl Service Center
Raleigh, NC 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 22]
Per NC General Statute 143 215.68 (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 o rule implementing this Article . shall be guilty of o Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars f510,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement)
[}� 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.
I he 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 information
will, abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part it (Starmwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II 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 drscharge(sl and is entorceable in the same manner as an
individual permit. rr—
Project Name (must match Ala): C.Gq'1 r'�P S - , f 7 C7 cJV
Specific Lot Numbers (must match Alb): F} 7)
Permittee (must match 81): - P-(! fVe- f-17 i2CC le- r
Legally Responsible Person (must match 82 & 83)_ /F�AQ—.
Title of Legally Responsible Person (must match 83b)
Name & Tide of Signed if Authorized Individual
Differs from Legally Responsible Person_ —
Phone Ne T!?tr.
IL
SrjgrTature o egisly Reslawst bit Person or Aulftviztd Individual Date
` lMPORTAW NOTE ?h.s" nest be signed br a rr4xyw4* corpayate 0iff%V mar mvnx Of ope_nvtes Me cvestrvr-rlar OrrvRY,
suth cs a prrsrderf, srVVrorr. tr mate- or vice preSiderot air a monoatr, Mot,. outr+kX rrd n4 weardonce with Part W. SKton A
Mir„ l6) o/ FfW FKG010" perm..t