NCC230918_NOI Signed Certification_20230403

NCG01 Notice of Intent (NOI) C.'ertification Form
Directions:
Print this form, complete, scan and uplo, :1 to the electronic NOI.
Then, Sail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check)
Division of Energy, Mineral & Land ResOU r --es Stormwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service C(!,.'titer
Raleigh, NC 27699•-.1-512
DO t )T MAIL THIS FORM OR PAYMENT UNTIL YOUR APPL,ii.AATION HAS BEEN ACCEPTED AS COMI
THE K ,M YOU MAUL MUST BE COMPLETED WITH AN ORIG011AL SIGNATURE (NOT DIGITAL) 140 CFR
Per NC Gene :11 Statute 143-215.6B fi), any person who knowingly n i rrkes any false statement, representation, o
certification 7 any application, record, report, plan, or other docum 1:1nt filed or required to be maintained under his
Article or a r le implementing this Article ... shall be guilty of a Cla'';,! 2 misdemeanor which may include a fine t to
exceed tent :,usand dollars ($10,000).
Under pens i of law, I certify that (check all boxes to indicate your• agreement):
l an
:he person responsible for the construction activities cii this project, for satisfying the requirement
of this
pert
it, and for any civil or criminal penalties incurred due to violations of this permit.
The
iformation submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and c
plete
for
bass
1 on my inquiry of the person or persons who manage -'::he system, or those persons directly respoi
sible
gat
;ring the information.
®
I wl
abide by all conditions of the NCG010000 General Per;.nit and the approved Erosion and Sedimeni
Control
Plat
if tl
, approved Erosion and Sediment Control Plan is not c ampliant with Part II (Stormwater Pollution
II the
Pre
=_ntion Plan) of the NCG010000 General Permit I will i ionetheless ensure that all conditions of Parl
of
per
fit are met on the project at all times.
I he
eby request coverage under the NCGO10000 General ;°'ermit and understand that coverage under
in the mar
his
ler as an
per
lit will constitute the permit requirements for the discharge(s) and is enforceable same
inc
ridual permit.
Project
ame (must match Ala): Q r,n 0&aAn
Specific:
of Numbers (must match Alb):
Permits
Legally
Title of
Name il
Differs
Phone
rN,
e (must match 81): Z d- CCr)
csponsible Person (must match B2 & B3):m
e!gaiiy Responsible Person (must match B3b): �� C—
Title of Signed if Authorized Individual
om Legally Responsible Person:
umber: _ -70 `F — 26
ignature of Legally Responsible Person or Authorized Irfdividuai
2-
IMPORT AfT NOTE: This form must be signed by a responsible corpa;! : to officer that owns or operates the constructio activity,
such as c ]resident, secretary, treasurer, or vice president, or a manqir?r that is authorized in accordance with Part IV, r
ction B,
Item (6) , "the NCG010000 permit.