NCC217117_NOI Signed Certification_20211222

Arfiicle or a rule implementing this Article ... Sha
exceed ten thousand dollars ($10 000)-V
NCGO1 Notice of Intent (N01) Certification Form
Directions:
Print th0
is form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources St ormwater Proramg
512 N. Salisbury Street., 6th Floor (Office 6--40K)
1612 Mail 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 122o22]
Per NC General Statute 143-215,.6B i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
11 be gui0 lty of a Class 2 misdemeanor which may include a fine not to
Under penalty of law, I certify that (check all boxes to indicate your agreement):
al 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.
The information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and complete
based on my 40 inquiry of the person or persons who manage the system
gathering the information.
or those persons directly responsible for
1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan,.
YJ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
dh
P f Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of I I e
14 ermit are met on the project at all times.
hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the Permit requirements for the discharges) and is enforceable in the same manner as an
individual permit. �
Project Name (must match Ala): I �'
Specific Lot Numbers- (must motch Alb : N�
40
Permittee (must match 81): , + ,� (l cSD� ✓ � 6LA
Legally Responsible Person (must matchB2 lix R-
4010w,):
Title of Legally Responsible Person (must match B3b): �(✓�
Name & Title o igned i uthor-S
ized Individual
Differs from Legally Responsible Person.
Phone Number:
Signature of Legally Responsible Person or
C�
e ndividual
Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer a', owns or operates the construction activity,
such as a president., secretary, treasurer, or vice president , or a manager that is authorized in accordance with Part IV, Section B,
Item (6J 0f the NC6010000 permit,,