NCC230779_NOI Signed Certification_20230328

NCGO1 Notice of Intent (NOI) Certification Form
MWAS119M
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources Sto/nwva1erProgram
5l2N.Salisbury Street, 6*Floor (Office 640K)
1G1JMail Service Center
Raleigh, 0[276gA'1612
DO NOT MAIL THIS FORM OR PAYNIENT UNTIL YOUR APPLICATION HAS, BEEN ACCEPTED AS COMPLETE.
THE TORM YOU MAIL MUST BE 4CIOMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122221
Per NC General Statute 243-225.68(i),any person who knowingly makes onyfobe statement, representation, or
certiP cation /nany application, record, report, pkzqorother docunnentfiledorrequired tubemaintained 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 ($2(lO0D).
Under Penalty oflaw, | certify that(check aUboxes to indicate your a0reemmend:
Viamthe person responsible "or the construction activities ofthispn�ec�for sad�yiogthe requirements ofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
[�V The information submitted |nthis NO! is, tothe best nfmyknowledge 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 mfthe NCG010000 General Permit and the approved Erosion and SedimentControl
Plan.
i/ if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure fhat all conditions ofPart Uofthe
permit are met onthe project atall times.
K/| | hereby request coverage under t'he un
derstand
permit will constitute the permit requirernents for the discharge(s) and is enforceable in the sarn-ernanner as an
individual permit.
-Project Name (mustmatch Ala): /.5,5 i:�
Specific Lot Numbers (must match Alb): /
Permittee (must match Bl):
Legally Responsible Person (must match B2 & B3):
Title of
3onsible Person (must match B3b):
Name & Title ofSigned if Authorized Individual
Differs from Le.-aDvResoonsib|ePerson:
rf �
' * �o-
ure of Legally Responsible Person or Authorized Individual
*IMPOel ANT NOTE: This form must be signed byoresponsible corporate officer that owns or operates the construction activity,
such osopresident, secretary, treasurer, n/vice president, o/omanager that isauthorized /naccordance with Part /KSection £,
item (6)rƒthe NCGO1O000permit.
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