NCC231591_NOI Signed Certification_20230524

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, St' Floor(Office 640K)
161.2 Mail Service Center
Raleigh, NC 27699-1612
LETE.
DO NOT MAIL THIS FORM OR PAYMENT
ET APPLICATION
GfNA1 S GNA URE{NOT D1G1 AL�OOP Pl z2)
THE FORM YOU MAIL MUST BE COMPLEB WITH AN OR
Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained include fine r not this
a
Article or a rule implementing this Article- . . shall be guilty of a Class 2 misdemeanor which may
exceed ten thousand dollars ($10,000),
of !coxes indicate gr='erne
�, law, Ithat (check allto =n_I:�-=� :�ou�-aG. -_.�:-,: _ .
Under penaltycertify
El
' ern the -person responsible for the construction activities of this 'project, For satisfying the r equ!rements of this
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, and
ons directly 5 JIlet`e�l
based on iT.J inquiry of the person or persons who manage the system, or i ...se
gathering the information
I 1 b, a!! c .d:`ic.._ cft'^:e NCG010000 General Permit 27 "- a'pp.:-oved Ir aSiOn _.
Pier r Sediment
m nt Control Plan not Cv.•rrtl,%rt-: .tilt P r ii (Stormwater PCI!::rion of
',-. n�t7�/=_ crOs�3it and ���i 2 .a�'••3c a!I f, r10itSnr's��f t�3!. 11
Genera! Permit, I will nonett-1"=encvr 4. t1
ci•� _�- - , Pi:-'! ^`t~^e 1'\iCG010000 .
germ, are: met onproject at all times
tne � -.''�-5�a:?1 that C•J�.2r35�.-
.r �i�t':�5
ge t r dc•r . NCG010000 General Permit and
I' F I i? repo r=_ptia]a_C4�rop_ - a ,'}?same manner as 'n it
the mit' . IJire ni5 for the dischargef s)and is er.fos':eabt in t
C=rrr'E will constitute -
InUl1 'J_lai v� Mlit. `
Project Name (must.match Ala): (-roan)) I - 0 la -- - — - �—
Specific Lot Numoers (must match Alb): --- - _ -- — —
t i
LiQ prtam find exs flumes - LLC., - -- - -- ----- -
�er'.11��tee �rlLlst r".iatrl s �_�-- '----_ -• --_--____.
Leslie Groves
Legally Responsible Person (must match B2 & 83) --_-- -- _ -- -- - -- -
-ide of Legally Responsible Person (must match 83b): UN
SIOh es►dent"
Name &Title 0` Signed if Authorized Individual
Differs from Legally Resoansible Person. - — —. _ _
Pho Numbe; 0 10_',86_486 )_ .._. — •— - — - - -_
y ,SIa3
'," Signature of Le ally esponslble Person or Authorized Irdividua'
Date
/MPOR/AN.+ NOTE: This `.arm must be signed by a respons;b'e corporate officer thatowns or ape;•oies the coostl"I i,a:Un ac:ivif'i.
such as a president, secret:;y, treasurer, or'ice president, urn manager (-hot is authorizer)in accordance !'vith Port i''J. 5ectrnn B
item (6)of the i\C 01'00001%e:rr);t