NCC217046_NOI Signed Certification_20211220

NCGO1 Notice of Intent (NOU) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form 10the NLDEK400omnwaterProgram (with $100 check ifpaying bycheck) at:
Division ofEnergy, Mineral & Land Resources StornnwaterProgram
5I2N.Salisbury Street, Gt'Floor (Office 64OK)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i),mny person who knowingly makes anyfalse statement, representation,
urcertification in any application, record, report, plan, or other documenthledmrequired to be maintained
under this Article ororule implementing this Article ... shall beguilty 4foClass 2misdemeanor which may
include oftnenot tuexceed ten thousand dollars /$10,0D8/.
Under penalty oflaw, | certify that (check all boxes toindicate your aBreemeMd:
0J |amthe person responsible for the construction activities ofthis project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
0Q 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 information.
UQ | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
X If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ufthe NCG010000 General Permit | will nonetheless ensure that all conditions of
Part Uofthe permit are met onthe project atall times.
Q0 | hereby request coverage under the NCGO10000 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 asanindividual permit.
Adventure Village Erosion Control
—Name of Project:
—Legally
nsible Person: Tanner Dale Owen
Title ofLegally Responsible Person: President
*Print Name and Title ofSigned ifAuthorized
Individual Differs from Permittee:
Phone Number: 828-802-5411
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the
construction activity, such ascpresident, secretary, treasurer, mvice president, nromanager that is
authorized /naccordance with Part IV, Section £\Item (6)ofthe NC6D10OOOpermit.
For more information on signatory requirements, see Part IV, Section B,ttem (6) of the NCGO10000 permit,