NCC222259_NOI Signed Certification_20220623

NCG01 Notice of Intent (MOIJ CertifKatlon Form
0 rectrpns
P-Int Ibis fwm. ca+"pietl. scan ar.d upload to the electronic NO
Ihon. mad the Original form tp the NC DfMLsI Sta+*rtweter Program I*it h 5104 Check rf polrurp Dr checkI at
Dnrrsron of ir+erg'r. Mineral i Land Resources Storrn*ater PTWertt
512 H Wrsburr Street, 6- FlOW 10IMte 640K I
1612 Ma I serv►te Center
Raleigh NC 276"-1612
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ArteCRr Or a rude v►fpi mtntMff thit Aftr{ie Slrofr Of 9%0* r df n Ctaas 2 Madrmranpr w!";rh --or rrrew* a f[rW pol to
e=trrd ten thou"Pd dafta fS14owl
Under PM►iFty Of l0 w I (ertlly that leheck 01 boxes to indi[ate you► apsernent)
0 1 an! the person responvwv tar the Ganstruct,on actIvrtrrs of this prowl. floe sattslyrry the evwfernerfu of tNs
parrmrt and sR* any civil of cr"inal Peat"*$ rntu■red due tp Wplatrorrs of t+sn permit
The rntoamalron wbrn►tted m t1+ts NO IS, to the best of my knpwledp anp tolyel true. accurate and complete
based or my rngwuy of the person or persons wA0 manage the %vat n at those Porwns directly rrspons4ge 1pl
gathe►;ng the +rrfr►rrnabron
0 I .rill abrer by ail Co+►dttrooi of the Per rijE and the 4opeaveo Con"
Plan
0 It the aparaved f ros*ry and Sediment Control P4ko rs not cornptlanl with Part li IStarmwater pollution
Pr ntron Plant of the n:: • I w'al "eWtheles1 ensure lhet all condawns pf Pert It of thr
permit are met on the prolott at all ernes
0 +hereby request cwrerage under th! -A; j6 y".y: �liPg+r+►'"• and urulenirne thm cvvttage under tnts
oefrmd w,11 Constitute the pe-rmit rrp+srromtmt3 fat tht dnchargelsi and +s #rrbat:eabie in the carat ►nenr►ri as an
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Title of LW#v Il�nsrble Person Imur: rratCh
clime ltr Tstje of SWted if Authortted Ind,vtdua
D•Hers from 4 i Ain smile Person
Phone Number: (8")y-371.1077 - ---
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