NCC231477_NOI Signed Certification_20230516

NCGO1 Notice of intent (NO1) 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 check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6:'' Floor(Office 640K)
163.2 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40O P PAYMENT UNTIL YOUR APLICATION HAS BEEN ACCEPTED AS R12222]
LETE.
THE FORM YOU MAIL MUST BE
Per NC General Statute 143-215.58(i), any person who knowingly makes ony false statement, representation, 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. . . shall be guilty of o Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars($10,000).
Under penalty of law; Ce�tlly that (check ai boxes toindicate your ac•=eme^
Q i am the person :esponsible for the construction activities of this protect, for satisfying the requirements of this
permit, and for any Civil or criminal penalties incurred due to violations of this permit.
theElof my knowledge and belief, true, accurate, and complete
The information submitted in this NOI Is:to best 7 �parsons directly responsible for
gatheringon my inquiry of the person or persons who manage the system, or those
the information
_. ],;i [he �I-., rJ Erosion cod �.•ter.',•-I:'�:�_��i�:_ --
I' abide `' Si'l ccr,d'tic ._ the N00010000 General Permit _ _ e _ _ .-i. _.
J'
Plat,
El If The Cnp'jr_r Erosion and Sediment Control Plan is not ccmpllan" (Stormw3te1 P;I;u-Io.;
nonetheless r_-lc��fr.o 7•^-r all conditions of Par':ll V: �_r1'_
Present dc-' Pian) of the NCG010000 General Permit, I will no s
permit are I-net cn toe project at all times
L . - - ,.hat�_y_i'n5° ' � �"' 't•"s
,�� :ne NCG010000 General Permit and - ;ty
{r-1'25J ram'»J_�i Ci��?r��'l]t vC� no
discharge(s)and i_ er.ioiceable in the same m;rnei
permit 4Vi{I CAl1yli:Ui� the per-nit r?i7'JICP_r"?eilis for tl�?
). COaYul Ia- 00 I
Project Name (must match Ala -
Specific Lot Numoers (must match Alb): ------ "- --- _
match 81): DY�,OIm flndeYS t't'!'Y1CS , LLG --- -- --- -
rr'2r''il,�tc2 �ri�List� � —_- - —
Groves
Legally Responsible Person (must match 82 & B3) _`�� _•_ -- - -
Title of Legally Responsible Person (must match B3b): Div\Sioln lol(e-SIGIert
Name &Title o Signed if Authorized Individual
Differs From Legally Responsible Person. --- _ - — _. --
Pho number:
9'10-'86-4864
4 /4)--C 3
Signature of Legaily r esponsible Person or Authorized Individua'
Date
NOTE: This must be signed by a responsible corporate officer that OWO'S or ape:'Otes the �ronstrLltion Ocrivlry'.
IM�LR I Al�J% formrrcCOi'Clonce with Part 1V, section B
such Os a presid`ant, secretory, treasurer. or vice president, or n manage, that I� cuthorized Ill
Item (' )of the NC,Oi'0000 re:r,Tt