NCC220474_NOI Signed Certification_20220127

Print this form, complete, scan and upload tothe electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy,Mineral 6\Land Resources 6tormwmterProgram
512N.Salisbury Street, 6*Floor (Office 64UK)
1612Mail Service Center
DONOT MAIL THIS FORM ORPAYMENT U YOUR APPLICATIONHAS BEENACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Per NC General Statute243-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification inany application, record, report, plan, mother documentfiledmrequired tobemaintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars /$1(I0DU/.
Under penalty nflaw, | certify that (check all boxes toindicate your agreemmemt):
�l 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.
LV] The information submitted inthis N0|is, tothe best nfmyknowledge 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.
�
r
c� | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions ofPart Uofthe
,permit are met onthe project atall times.
|V1 ) hereby request coverage under the NCGO10000 General Permit and understand that coverage underthis
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 Ala): Lake Lynn Greenway Repaving
Soecific Lot Numbers (must match Alb): see attached
Permittee (must match Bl): City OfRaleigh
O8C8rCarmOOa
—Legally Responsible Person (must match B2 & B3): Title of Legally Responsible Person (must match E13b): Director of Parks, Recreation, & Cultural Resources
Name & Title ufSigned ifAuthorized Individual
Differs from Legally Responsible Person:
�1�-�96-4815
Phone Number:
�
Sigri—ature of Legally Responsible Person or Authorized Individual
0 L'?'
Date
*IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns moperates the construction activity,
such mopresident, secretary, treasurer, or vice president, momanager that is authorized in accordance with Part IV, Section B,

Specific Lot Numbers: 0774-96-3627, 0787-98-1355, 0787-97-2528, 0787-86-8949,
(must match Al B) 0787-96-2702, 0787-96-5411, 0787-95-0651, 0797-05-2463,
0787-93-5768, 0787-94-7488, 01797-04-9792, 0797-03-4756,
0797-03-4263, 0787-92-4683, 0797-02-2658
Signature of Legally Responsible Person Date