NCC223740_NOI Signed Certification_20221107

NCGO1 Notice of Intent (NQl) Certification Form
Directions,
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program (with 5100 check if paying by check} at:
division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 5* Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL Y0UR APPLICATION HAS 8 E E N ACCEPTED A5 COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETER WITH AN ❑RIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122,221
Per NC General Statute 143-215_68 (0, any person who knowingly makes any false statement, representation, or
certification in any application, record, report plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article. shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars 1$10,000;_
Under penalty of law, I certify that (check all boxes to indicate your agreement):
[]r l 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.
✓[] The information submitted in this NOI is, to the best of my know}edge 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 NIC19000 General Permit and the approved Erosion and Sediment Control
Plan.
Q If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO1 OOOQ kt.neraI Permit I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times.
Q I hereby request coverage under the NCQ010000 Gerseral Permi[ and understand that coverage under this
permit will constitute the permit requirements for the discharges) and is enforceable in the same manner as an
individual permit.
Project Na me (must match Ala): Connolly Job
Specific Lot Numbers (must match Alb): tot 100
Howell Technologies Inc.
Pcrrnittee (must match BI l:
Legally Responsibly Person (must match 82 & 83): Kenneth Howell
Title of Legally Responsible Person (must match q3> ): President
Name & Title of Signed 0 Authorized individual
Differs from Legally Responsible Person:
Phone Number-
828-312-9221
Signature of Legally Responsible Person or Authorized Individual
Date
IMPORTANT NOTE_ ThiS for►rr must be signed by a responsible corporate after that owns or operates the torts (ruction act)vity,
such as a president Secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section 8,
(tern (6) of the NC6010OW permit.