NCC220391_NOI Signed Certification_20220120

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC D[ MLR Stormwater Program (with 5100 check if paying by check) at:
Division of EnciFy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor (Office 640K)
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 122.22J
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 a rule implementing this Article ... shall be guilty of o Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
0 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.
Q The information submitted in this NOT 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.
Q I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Pian.
Q If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGOl0000 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 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 as an
individual permit.
Project Name (must match AI a): Robeson Food LLC DBA Moe's & Schlotzsky's
Specific Lot Numbers (must match Alb):
Permittee (must match 81): Amblka of Lumberton
Legally Responsible Person (must match 82 & B3)_ Harry Jhala_ `
Title of Legally Responsible Person (must match B3b): Owner -
Name & Title of Signed if Authorized Individual N/A
Drtfers from Legally Responsible Person- - — -- -_ -- -- _
Phone Number: 910-740-9y29 -
s+gnatur t L-egally Rr4,ponsible Perwn or Auttkifued Individual
1118122
Date
• IMPORTANT NOTE: This form must be siyned by o rrsponsible corporate offuer that owns or operates the construction activity,
such os o president secretary, treasurer, or vice president, or a munager that is outhonzed in occordonce with Part IV, Section B,
Item (6) of the NC6010000 permit.