NCC221627_NOI Signed Certification_20220427

NCG 01 Notice of intent (NO1) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI,
Then, mail the anginal farm to the NC €]EMLR Storrnwater Program (with $1n0 check 1f payr'ng by check) at:
Division of Energy, Mineral & Lend Resources Storm ater Program
512 N. Salisbury Street, 61^ Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 77699-1612
DO NOT MAIL THIS FORM OR PAYMENT UhMLYOUR APPLICATION HAS SEEN ACCJEvrrCO ASCOIHPLETE.
THE FORM YOU ixRAIL MUST BE CQMRLETEb_WItFi AN ORIGINAL SIGNATURE (NOT DIGTFAL) MOOR 1Z J21
Per NC General Statute 143-215.68 (i), any person who kno wingly makes any false statement, represen ration, or
ferti cotton in any application, record, report, plain, or other document filed or required to be rnaintained under this
Article ar a rule implementing this Article ... shall be guilty of a Class misdemeanor which moy include u fine not to
exceed tern thousand dofiars (10,OOQ).
Linder penalty of law, I certify that (check all boxes to indicate you agreement):
® l am the person responsible For the construction activities of this project, for satisfying the requirements of this
permit, and far airy civil or criminal penalties incurred due to vioiations of this permit.
The Information submitted in this N Q G 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 di►ectiy responsible For
gathering the information.
I will ahide by all conditions of the i ICGO10000 General Perm and the approved Erosion and Sediment Control
Plan.
FZ If the approved Erosion and 5edirnent Control Plan is not campliantwith Part 11 (StorrAwater Pollution
prevention Plan) of the NCGO10000 General Permit. I wlII nonetheless ensure that ail conditions of Part 11 of the
permit are rnet on the project at all lorries,
EZ J hereby request coverage -under the NCG01CMQ General Permit and understand that Coverage under this
permit w !11 constitute the permit requirements far the discharge(si and is enforceable in the same manner as an
individual permit.
Pro je ct N ame (must match Al a); Twin Lakes
cific Lot Numbers (must match Alb): Lot 3
Permittee (must match 81): Uma P asireddy
Legally Responsible Person fmust match 82 & R3): Uma Kasireddy
Title of Legally Responsible Person (must match 33b): Owner
fume & Title of Signed if Authorized Individual
Differs from Regally Responsible Person;
Phone Dumber: 0 -631- 087
Signature of Legally Responsible Person or Authorized individual
r
Date
* IMPOMIANT NOTE; This farm MUst be signed by a respanslbfe corporate officer that Owns or operates the conaxactfon actfv11y,
such as a presfden� secretory, treasurer, or vice president, arc manoper that fs authorized fn ocrordance with Parr 1V, Sectkn 8,
ftem (51 of thL- NCGO10000 permit.