NCC231480_NOI Signed Certification_20230516

NCGO1 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 check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
57.2 N. Salisbury Street, 6" Floor(Office 61-1-0K)
167.2 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 DIGIT AL) [40 CFR 1.22.221
Per NCGenera!Statute 143-215.58(i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or oth er document filed or required to be maintained 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($10,000).
hindicate your agre,`rnen.`(:
Under penalty of law, Ce't!i��that (check
�:` boxes .
i am the person responsible for the construction activities of this project, For satisfying the requirements of this
permit, and for any dull or criminal penalties incurred due to violations of this permit.
0 The information submitted in this NOI 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
gathering the information
NCG010000G and the _pp:rr, Erosion andSe 'm'e - -
I�' � � 'lt abide by �.l! �r. ..�.t!'�.:5 .,- t'�.a antral Permit -� - -, - --. _.
Plan
IfSediment Control Plan is of cl_.m,pii
r,; ;nwith Part it (StormwEer Pcl:J:!a l
the G��,•rj�=A �r��i�'J'r. and �c•aiir L~ e�c•E(fl 1^3!all rrnpiicrts of!�a!:II Of}1�
Pre-enr;.c _-1 c`r e NCGO10000 General Permit, I will nonel:r'el_oC rs-_
permit are rnet on the project ai: all times.
10000 erah_
(� � er the NCGO General Permit and -'1�`-'ital'j thatc�"-
I�' l I '' �,�y '= -J�:Si=ib=row-til u-
•till -.31n5titUZC the perm rec'iirer Tents for the discharges)and is enforceable in the Same I •3O'tei al an
UO .flit
Project Name (must match Ala): -rcoyo I - 0 OS — —
Specific Lot Numoers (must match Alb): ---- �- — —
Permittee (must match Bl): DYeam find el(s ilromes , PLC ___—__- _-- -- - -
Legally Responsible Person (must match 82 & B3)_esIl� Groves
— -
Tide of Legally Responsible Person (must match B3b): DIV IslOI(1 YYCSIderr1'
Name &Title o"Signed if Authorized Individual
Differs From Legally Responsible Person. ` _^ — _ • - ---- --- — _
9-10-486-486 !
Pho Number, — — ---•-
(4CW ite
Signature of Legally sponsible Person or Authorized Individual Date
• IMPORTANT NOTE: This form must be signed by a responsible corporate ajfine'r that awns or Operates the rocsitrLi tion cicr,Viry.
such as a president, secretory, treasurer. nr Vice president, or a manage' that is uur,thorizerl in ricnarrionce with Part I`✓, Section rB
Item(6) of the NC Oi'7000 ne:mit