NCC220879_NOI Signed Certification_20220301

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 DEMLR 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 BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122.221
Per NC General Statute I43-215.6E (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.
❑2 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 NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
If the approved Erosion and Sediment Control Pian is not compliant with Part II (Storm water Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
0 I hereby request coverage under the NCG010000 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): Morrisville Fire Rescue Department Station #3
Specific Lot Numbers (must match Alb):
Permittee (must match B11: Town of Morrisville
Legally Responsible Person (must match BZ & B3): Martha Paige
Title of Legally Responsible Person (must match B3b): Town Manager
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 919-463--6150
Signature of Legally Respon
e Person or Authorized Individual
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Date
IMPORTANTNOTE.- this form must be signed by a responsible carporote officer that awns or operates the construction octivity,
such os o president secretary, treasurer, or vice president or a manager that 6 authorized in accordonce with Port IV, Section 6,
item (6) of the NCGOI0000 permit.