NCC221809_NOI Signed Certification_20220511

NCGO1 NotIF
ice of Intent (NOI) Certification Form
Directions..0
Print this form, complete, scan and upload to the electronic NDI.
Then, mail the original form to the NC D E M LR Sto r mwate r Program (with 5I00 check if paling by checks at -
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th 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) 140 CFR 11,22.rU)
Per NC Genera! Statute 143-215.6B (1), any person who knowingly makes any false statement, representotron, or
certification in any application, record, report, plan, or other documentfiled or required to he maintained under this
Article or a rule implem en tin q this Article ...shall be gurlty of Q Class 2 mrsdemeanar wh1ch may inclu de a fine not to
exceed ten thousand dollars t$10
.r000).
Under penalty of haw, 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.
El The information submitted in this NO1 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.
EIr 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
12/ If the approved Erosion and Sediment Control Plan is not compliant with Part li (Stormwater Pollution
Prevention Plank of the NCG010000 General Per I will nonetheless ensure that all conditions of Part If of the
permit are met on the project at all times.
F71 I hereby request coverage under the NCG010000 General 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.
Project Name (mush match Ala). Qzde Pop
Specific Lot Numbers (must math Abb):
Perm�ttee (must match B1}:
Legally Responsible Person (must rrrorch 82 & B3):
Title of Legally Responsible Person (must match B3b),,WY7 en .,
Name & Title of Signed if Authorized Individual
Differs from legally Respons(ble Person:
Phone Number. � z `" ����
0
OOPF
SigrWrq/of Legally Responsible Person or Authorized Individual
ate
ZoZZ
* IMPORTANT T T form must be signed b 12 responsible corporate officer that n or erate the construction a i
such .rnr#secretary, treasurer., or vice president, or io manager that is authorized in accordance with Part IV, Section B
Item ffi) of the NCGO10000 permit