NCC230056_NOI Signed Certification_20230111

NCG01 Notice of Intent (NOI) Certification Form
Directions-
Print this form, complete, scan ar►d upload to the electronic NOI
1 Mrri, mad the original fora+ to the NC DEMLR Stormwater Program (with 5100 check if paying by check) at:
Dan -won of Enemy, Mineral 8 Land Resources 5tormwater Program
512 N. Salisbury Street, 6- Floor #Office 640K)
1612 Mail Service Center
Raleigh, NC 27699, 1612
DO NOT MAIL THIS FORM OR PAYMENT
UNTIL YOUR APPUCATION HAS BEEN REWE1 ED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215-68 i'l1, ariy person who knowingly makes oily false statement, representation, or
c erlificurlon in any appricatlon, record, report, plan, or other documentflied lied or required to be maintained under this
Article at a rule lmplemenbrig this Article. _ . shall be guilty of a Class 2 misdernearwr which may include o fine not tip
exceed ren thousand dollars ($10,000)-
kinder pe-nalty of law, I certify that (check all boxes to indicate your agreement)-
yl I am the person responsible for the congmctiort activities of this project, for satisfytng the requirements of this
Permit, and for any civil or criminal penalties incurred due to vialation5 of this permit.
lire information Submitted in thus N01 is, to the best of my knowledge and belie!, 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.
1 will abide by all canditions of the NCG010.W General Per and the approved Erosion and Sediment Control
Plan
if the approved Erosion and Sediment Control Plan is not compliant with Pan 11 (5tormwater Pollution
Prevention Plan) of the f rWl0000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met an the project at all times.
i hereby request coverage under the NCGOLM General P rm.t and understand that coverage under this
permit will constitute the permit requirements for the discharge[s} and 1s enforceable in the same manner as an
mdivr dual permit
Name al Project (must match AIa): ,
Specific lot Numbers (must match Alb): W
legally Responsible Organizational Entity (must match g1): Dg f1, w_ % V A r q a&�,
Lela I ly Re sparisible Person (must match B2 A 933), p o rw , t u &r 9 cx -,7
Title of Legally Responsible Person (must match 83b): n ,s r,e r
Name & Title of Signed if Authorized Individual
Differs from legally Responsible Person:
Phone Number: CA} q - yl1- LA rl I_r�
� M_ r' e/ 1/cry Z a S lra[ a d C-C
Signature of legally ae ponsible Persw or Authoriged Individual
Date
IMPOVANTPM M-- This form roust be signed by a responsible corporate after rhat owns or uprnates the cwWnxtion aamty,
such rat a pngident, wrerory, treasumr, or vncr presiaenr or a mori*Wr char is eluthorited in accordance wail Pon rV, Sacrron 8,
earn t6} of the NCWJ0CWp,errrr1r.