NCC230393_NOI Signed Certification_20230213

NCC01 Notice of Intent (NOI) Certification Form
wrections:
Print this form, complete, scan and upload to the electronic NOI,
Then, mail the original form to the NC 17EM LR Stormwater Program (with $100 check tPoY+n9 by cheat) at:
Division of Energy, Mineral & Land Resources Stormwater Prograrr,
512 N. Salisbury Street, 611 Floor {Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
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 122.221
Per NC Generic Statute 14.3-215.66 (1), any person who kno wingly makes arly Nse stn semen r, representation, or
certiftcRtror; in any application, record, report, plan, or other [lorurxrerrt filed ar required to be Maintainedunder this
Article or a rule implementing this Art0e . , . shall be guilty of a Class 2 m+sderrrear+or which may include R fine not to
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreemers't}:
UJ-1 am the person responsib a for the Construction activities of this project, far 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 N01 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
Unil
ring the inforrnartion,
abide by all conditions of the NCG010D00 General Permit and the approved Erasion and Sediment Control
Plan.
the approved Erosion and Sediment Control Plan is not Compliant with Part I (Storm Ater Pollution
Prevention Plan) of the NCG010000 6eTlera I Permit, I will nunetheless ensure that all conditions of Part 11 of the
permit are met on the project at all tirnes.
I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge{s) and is enforceable in the sa me manner as an
individual permit.
Project Name (must match Ala):' v
Specific Lot Numbers {must match A1b;-
Perm ittee (must match 81),
j r?E 5V r e
�rdr' L C
—Legally Responsible Person (must match B2 & a3}= A
Title of Legally responsible Person {must match B3b):
Name & Title of Signed if Authorized Individual
aiffcrs from Legally Responsible Per�ori
Phone Number: 7 19 Y t t10 0 `
f
�Siture f aII
g a eg y Res pon le per on or Authorized Individual
3
Date
IMPORTANTNQTE. This form must be signed by a m5pansrbie carPurtrte officer that owns or operatFS the construction attMty:
suers os a president, secretary, Treasurer, orvice Pre5rdent, or rnanCgerthoti5 authorized in accordance with Part IV, Section 8,
item 16) of the 1VCGQ10000 per-mit.