NCC232172_NOI Signed Certification_20230721

NCG01 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 DEMIR Stormwater Program(with S100 check if paying by check)at
Drvisron.'of Energy, Mineral& Land Resources Stormwater Program
512 N Salisbury Street,6• floor(Office 640K)
1612 MadService 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 DIGITAL) (40 CFR 122.22)
I'er NC General Statute 143 215 68 N. 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 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)
Under penalty of law. I certify that (check all boxes to indicate your agreement)
I am the person responsible for the construction activities of this project,for satisfying the requirements of this
permit,and for any civil or criminal penalties incurred due to violations of this permit
•
pilThe 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
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
Plan.
/[2:1 If the approved Erosion and Sediment Control Plan is not compliant with Part II(Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of Part II of the
permit are met on the project at all times
4 I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
pet mit will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit
Project Name(must match Ala). Intl '> )`t.A i 1_ I c,-} Li — — —
Specific Lot Numbers(must match Alb) te, 1 (`,�, .Z
Permittee(must match B1) -•A ,,1 ��,r , 11,, ,t, Jo I cri )L t'gi y1 .;
legally Responsible Person (must match 82&B3) j ,t:.i ,,-1 v_t t-;i 11 .k. )c i i ;.(c v t t;l i
Title of legally Responsible Person (must match B3b) ,�:, ._i,lt 1,y.1,1el L,
Pint Name& Title of Signed if Authorized
Individual Differs from legally Responsible Person Nit t4
Phone Number r i(
C. 'gnawof II:,ally Responsible Pers or AutVr(red Individual Date
• IMPORTANT NOTE: This form must be signed I a responsible corporate offerer that owns or operates the construction n uc twit y,
Sal hi us a aresuleal sic,Crory, treasurer, or tare president,or a manager(hot is outhunted al uccordu PI,i• with Pu'(fb. Sec bon ti
Item(6)of the N00010000 permit