NCC220265_NOI Signed Certification_20220113

NCGO1 Notice of Intent (NOl) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
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 Stormwater Program
512 N. Salisbury Street, 6, Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
00 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
NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representation, or
rtification in any application, record, report, plan, or other document filed or required to be maintained under this
title or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
cceed ten thousand dollars ($1Q000).
ender penalty of law,1 certify that (check all boxes to indicate your agreement)
11fl am the person responsible for the construction activities of this l;- watt, for satisfying the requirements of this
permit, and for any civil or cr%minai penalties Incurred due to violations of this permit.
The inlormation submitted in this N01 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.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
dif the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of Part 11 of the
permlt are net on the project at all times.
i hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit wilt constitute the permit requirements for the discharge(sl and is enforceable in the same manner as an
individual permit.
Project Name (must match Ala): '�) La'O- `C ? L.)�' 'Z C L
Specific Lot Numbers (must match Alb)'.`��
Permittee (must match B1): 1c/`� Pjj��+n L
Legally Responsible Person (must match 82 & B3): L_, 1 �,�nr� nz_ �_c_ IL
Title of Legally Responsible Person (must match 63b):
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person: `J _
Phone Number:
Sign tore o Legally Responsible Person or Authorized Individual Date
IMPORTANTNOTE: This form must be signed by a responsible corporate officer that 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 f6f of the NCG010000permit