NCC220495_NOI Signed Certification_20220217

CG01 Notice of Intent (NO]) Certification Fort
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEM LR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BUN ACCEPTED A5 COMPLETE,
H1 1 I you ,-11.,9 MUST.131= COMPLETE W....-t AN OR1G1NAL Sty }XTOIII ;aNQT �SIGITAL} [44 CF13 422 22
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 a 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):
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.
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.
I will abide by all conditions of the NICG010000 :; neg Penn t, and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG0100100 General Pert -,sit. I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
I hereby request coverage under the �U: 0143I 00 "'ener_�" 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.
Name of Project (must match Ala): Spencer VFD
Specific Lot Numbers (must match Alb): NIA
Legally Responsible Organizational Entity (must match B1): Spencer Mountain Road VFD
Legally Responsible Person (must match B2 & B3): Gary Hilton
Title of Legally Responsible Person (must match B3b): Deputy Chief
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 704-922-4747
* IMPORTANT NOTE: This form must be signed by a responsible corporate of.fithat 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 8,
Item (6) of the NCG010000 permit.