NCC230616_NOI Signed Certification_20230307

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, 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 the
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th 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 COMI
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representatio
certification in any application, record, report, plan, or other document filed or required to be maintained ur
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fi
exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
❑✓ I am the person responsible for the construction activities of this project, for satisfying the requiren
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 knowledge and belief, true, accurate, an
based on my inquiry of the person or persons who manage the system, or those persons directly re.
gathering the information.
❑✓ 1 will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sedin
Plan.
�✓ If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Polluti,
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
permit are met on the project at all times.
�✓ I hereby request coverage under the NCGO10000 General Permit and understand that coverage un(
permit will constitute the permit requirements for the discharge(s) and is enforceable in the same r
individual permit.
Project Name (must match Ala): Two Hearted Solar
Specific Lot Numbers (must match Alb):
Permittee (must match Bl): Pine Gate Renewables
Legally Responsible Person (must match B2 & B3): Ben Catt
Title of Legally Responsible Person (must match B3b): CEO
Name & Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
Phone Number: 7722145773
re of Legally Responsible Person or Authorized Individual
Date
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the construct
such as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part I
Item (6) of the NCGO10000 permit.