NCC221567_NOI Signed Certification_20220421

NCG01 Notice of Intent (N01) Certification Farm
Dir-ectialls-
Print this form, complete, S43n and upload to the electrorhit NO1.
Than. mail the onirlai form to the NC DEMtR Stormwater Program Iwit h S1DO che-ck if poying by cheek} at -
Division of E nergv, M i rteral & La nd Resou ryes Storrinwate r Program
512 N. aalisburV Street. IS,, FIon r {Office )
1612 Ma Center
Rale4h, NC 27699-1612
DO NOT MAT THIS FORM 011 PAYMENT UWT11. YOUR APPLICATION HAS BEEN AECEPTEC. A5 CDMPLETE-
THE FORM YOU MAIL MUST RE COMPLIFIED WITH AN ORICINAt 5l:GN4TURE INOT OriGIIA-.] 140 CPR 122-2Z]
Pre NC (�eneraii Staram, 293-215.69 (i), orgy Person who kno►vingq V moires any false storerrvnt, representation, or
cer rfica�i rr On Cn y aoNieariori, reeved, report, pion, f�r orher docijrnent filood or mquir'-d to be nroin ro;ned UrFder lhrs
Article er o role in7�f�m errrirrq this ArtiCle , - . shah be guilty of o Class 2 mrsdeffleorw which may incfvde a fine nol to
exceed ten rhowond dofiars �510,0 ).
Under penalty of law, I certily that (check all boxes to Indicate your agree ment)
14 I a the PerSOn responsible fof t1he construction activities of this project, for satisfy a%g the regoirerttents of thtS
permit, and for any cW a Criminal penaltiffs incurred due to viola ti00.9 8F 1hi-5 perniIi
The information submitted in this NO is, to the best of my knowledge and belief, true, ac�urate I and complete
based on my inquiry of the Person or persons who manage the system, or th#Se person-sdirectly' reSpor+Stble for
gat herin.& the information.
LP
I will. abide hV all conditions of the, NCGPI0000Generat.PermiI and the approved Erosion ar.d Sediment Control
Plan.
If the 0PpFaved Erosion and Sediment Cnrti O Man is trot cornptiant with Part 11 IStormwater Pc)lIution
T� Prevention Plan) of tfr e NCgZQJD200 Genwra[.�frrnit. I will nonetheless ensure that all conditions oI Part II of the
permit are met on the project at all times.
hereby request coverage under the NGGO10000 General - rmit and understand (hat coverage under this
permit will Constitute the permit requiremertts forthe dischacge(s] anti is enforCeah I@ in the same manner as an
i.ndividuai permit.
Project Nome (arose match Al GM; �r F-r: K T P
Specific: Lot Numbers Irmosf match Alb)-
Pe rmittee (must ma C[h 63 ,
Legally ROILP0 Sable Person Jrnusr march 92 & 83)= Q
— - t
Title of Le all* Responsible Person (must nwtch 83b); ;
Name & Title of Signed if Ant h oriied I nd lvidua 1
Differs from Legal ly Respo nsi ble Persow
Phone Number, -� J "7—
Sigrrat r Leg llyr Rep nsible Persoa or Authorized Ind ivMual
� 101 -2-1-
Vate
WPORTANTWIFE. Thrs form miv%t be vaned by o responsr'Ne C-Dwrate officer [hor owns lorovrotes [he cans[Fuclrorr activity,
A uch 42s b presidejrt secretary; frea3mver Qr wrCC prrsiderFr, or a onl2glrr Mar is a whvrired fm ewrordance W fh flart rv,-S-WiOet 8,
item (6) of [be mcGolmm permit.