NCC222535_NOI Signed Certification_20220803

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NCGO1 Notice of Intent (N01) Certification Form
Directions:
the electrODic�NO�
Print this form, co+nPlefie, Scan and upload to
+fpaying by check) at:
mail the original form to the NC DEMtR Stormwater Program (witheC Program
Then, Mineral & Land Resources Stormwat
Division of Energy,
512 N. Salisbury Street, 6th Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
D4 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS O F P1�2 ��ITHE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL[40
Per NC Genera! Statute 143-115.68 (i),
any person who knowingly
makes any false storement, representation, or
ord re ort, plan, or other document filed or required to be maintained a unfinder not to
certrfi�at this
+on in any applicotron, rec P
implementing thrs Article ... steall be guilty of a Class z misdemeanor which may include
Article or a rule �mp�e g
exceed ten thousand dollars ($10, 000)v
Under penalty of law, !certify that (check all boxes to indicate your agreement):
El I
am the person responsible for the construction activities of this project, for satisfying the requirements of this
and for any civil or criminal penalties incurred due to violations of this permit. complete
permit,
_ _.� �.,.,.,,� try �a arr-�jrate. and
0 The information submitted in this N01 is, to the best manage the system, or those persons directly responsible for
nu ut:: c , 1
based on my inquiry of the person or persons whog
gathering the information.
1 will abide by all conditions of the
NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
if the approved Erosion and Sediment Control Plan is not compliant with Part If (Stormwater pollution �4 of the
ion Plan)of the NCG010000 General Permit, 1 will nonetheless ensure that all condittonPrevent
permit are met on the project at all times.
under the NCG010000 General Permit and understand that coverage under this
manner as an
(�c] [ hereby request coverage
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same ma
individual permit.
Project Name must match A10)a
Scific Lot Numbers (must match Alb).-
pe
AL
Permittee (must match Bl): (�' -� �� `
legally Responsible Person (must match 82 & B3): >
n y-
-Title of Legally Responsib4e Person (must match B3b):
Name & Title of Signed if Authorized Individual
Differs -from Legally Responsible Person:
Phone NumbSb
er: � �-
Signature of Legally Respon ible Person or Authorized Individual
Date
*iMpORTANTNOTE.0, Thisform must be signed by a responsible corporate officer that owns or operates the construction nctry y,
ON
knoweage