NCC221096_NOI Signed Certification_20220328

NCGO! 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 rf paying by check) at:
Division of Energy, Mineral & Land Resou'ces 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 RE COMPLETED WITH AN ORIGIOAL SIGNATURE (NOT DIGITAL)140 CFR 122.221
Per NC General Statute 143-215.68 fl). any person who knowingty makes any false statement, representation. or
certification in any application, record, report, plan, or other document fried 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 f$10 DUO).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
M 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 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 respons(ble for
eatherintr the information.
✓❑ I will abide by all conditions of the NCGO10000 General Peqnit and the approved Erosion and Sediment Control
Plan.
�✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the oroiect at all times.
Q✓ 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.
ect Narre (must match Al.): Depala Foods
c Lot Numbers (must match Alb): Parcel ID 183622
Permittee (must match 81)- 2010 Oak Parkway LLC
Ily Responsible Person Imust match 82 & 831: Giusto Piraino
Title of Legally Responsible Person (must match 83b): Owner
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 704 (363) 2825
r of a ly Responsible Person or Authorized Individual Date
iMpORTANT NOTE. 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, Ora manager that is authorized in accordance with Part IV, Section 8,
rtern 16) of the NC6010000 permit.