NCC230327_NOI Signed Certification_20230203

NCGU.1 Notice of Intent (NOI) Certification Form
Directions:
Print this farm, complete, scan and upload .to the electronic NOI.,
Then, mail. the original form to the. NC DEMLR:Stormwater Program (with $100 check.if paying`by check) at::
Division of Energy, Mineral. & Lard Resources Stormwater Program
5.12 N..SalisburyStreet, 6ih Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 2769.94612
D❑ NOT MAILTHIS. FORM OR PAYMENT UN.T.f.L YOUR APPLICAT] ON HAS BEEN ACCEPTED..AS COMPLETE.
THE: FORM.Y.OUMAIL,MUST ' BE. CoMP:LEErE13:;WITH ..AN: kidINAL.;5i.GNAT[J.Rt.(I�b7 oiGIfAl):[�0':dt.. 24221
Per NC General Statute 143-215.68 (1), any person who knowingly`mokes any false. statement, represen.tation,. 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 ... sholl.:be guilty of a Class 2 misdemeanor which may include a fine not to
exceed tern thousand dollars ($10 oao):
ilnder penalty of law; I certify that (check .all boxes to indicate your agreement):
0 I am the. person resp.onsible.for the construction activities: of this project,..for satisfying the requirements of this
permit; and fo.r any civil.or crim inaLpenaIt! es incurred due'to violations of thiis permit.
❑d The information submitted in this N0I isi to the best of my knowledge and be!lef, true, accurate, and complete
based on my inquiry of the person or persons who manage the.system, or thos.e.. persons directly responsible.for
gatheringthe information.
0 I will abide by all conditions of the NCG010000 General Permit .and the approved Erosion. and Sediment Control.
Plan.
[]J if the. approved Erasion and. Sediment Control Plan -is not.compliant with Part II (Stormwater Pollution
Prevention Plan) of the. NCG010000.General Permit, l will nonetheless .ensure that all conditions of Part II of the
permit are: met. on. the project at aI times.
F71.Fhereby request. coverage under the NCG010000 General Permit 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 Name (mustmotch A1a): Agnes Binder Weisiger Breast Health Center
Specific.Lot Numbers (must match A1b): 15-20
Permittee (must match 8I): Novant Health, inc.
.Legally Responsible Person (must match B2 & 83): Matthew Stiene
Title of Legally Res Pons ible.Person. (must match 83b): Sr: V.P. Construction and Facility Services:
Name & Title of Signed if:Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 7047316-4351
Signature of Legally Responsible Person or Authorized Individual
Z_7--- zS
Date
IMPORTANTNOTE., This form must be. signed by a.responsible corporate officer that owns.ar operates the. construction activity,
such as a president, secretary treasurer,. or vice president, or a manager that is authorized in accordance with Part IV, 5.ection'8,.
Item (6) of the NCGO10000 permit..