NCC222457_NOI Signed Certification_20220708

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 DE MLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, N ineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6,h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENY UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST OE COMPLE EID WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22,1
NC General Statute 143-215.6B (i), any pers n who knowingly makes any false statement, representation, or
ification in any application, record, report, plan, or other document filed or required to be maintained under this
cle or a rule implementing this Article ... sh ll be guilty of a Class 2 misdemeanor which may include a fine not to
?ed ten thousand dollars ($10,000).
nder penalty of law, I certify that (check all boxes
to indicate your agreement):
V'
I am the person responsible for the construction
activities of this project, for satisfying the requirements of this
r-ypermit,
and for any civil or criminal penalties
incurred due to violations of this permit.
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 responsible for
gathering the information.
I will abide by all conditions of the NCG
10000 General Permit 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 Ge
eral Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
I hereby request coverage under the N
G010000 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.
Name (must match Ala): L o�e- 3+ VA !T bP_I—d ee
I nt NumhPrc (mutt match Al h)-
Permittee (must match B1): Qp
Legally Responsible Person (must match B2 B3): L3j S esL
Title of Legally Responsible Person (must m tch B3b):
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: l ti]
Signature of Legally Responsible
Authorized Individual
Da
IMPORTANT NOTE: This form must be signed by re' ponsible corporate officer that owns or operates the constru ion activity,
such as a president, secretary, treasurer, or vice p esi ent, or a manager that is authorized in accordance with Part Section B,
Item (6) of the NCGO10000 permit.