NCC223737_NOI Signed Certification_20221103

NCGO1 Notice ofIntent (NO) Certification Form
Directions:
Print this form, complete, scan and upload 10the electronic N[U.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources StonnwaterProgram
512N.Salisbury Street, 6mFloor (Office G4DK)
1G12Mail Service Center
Raleigh, N[27699-151Z
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) [40 CFR 122.22]
Per NC General Statute143-215.6B (i), any person who knowingly makesmnyhalse statement, representation, or
certification inany application, record, report, plan, or other documentfiled or required to be maintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars /$1[\0U0>.
Under penalty uflaw, | certify that (check all boxes tnindicate your :
,V 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.
VThe 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.
z� | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and Sediment Control
ifthe approved Erosion and Sediment Control Plan isnot compliant with Part U nmvva|erPoUution
- Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditkzm" Po�Uofthe
~ `p
permit are met onthe project atall times.
^L� | hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the dischav8e(s)and is enforceable in the same manner esan
individual permit.
Soil
-Name of Project (must match Ala): PTVE Landfill Area C Upper -Specific Lot Numbers (must match Alb): 8647-76-6665
Legally Responsible Organizational Entity (must match Bi): Blue Ridge Paper Products, Inc DBA Evergreen Packaging
Legally Responsible Person (must match B2 & B3): John McCarthy
Title of Legally Responsible Person (must match B3b): MillManager
Name & Title ofSigned ifAuthorized Individual
Differs from |Responsible
Phone Number: 828-748-5636
Signature ufLegally Responsible Person orAuthorized Individual / [(ate
* IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such as a president, secretary, treasurer, or vice president, or a manager that isauthorized /naccordance with Part IV, Section i\
Item (Qofthe NCG000O permit.