NCC232269_NOI Signed Certification_20230731

NCGO1 Notice ofIntent (NOU) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO|.
Then, mail the original form to the NC DEhALR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral 8' Land Resources 3tornnwaterProgram
S12N. Salisbury Street, 6`^ Floor(Office G40K>
1612 Mail Service Center
Raleigh, NCI76y9'161Z
0O NOT MAIL THUS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40CF0122.22]
Per NC General Statute 143-215.6B(i), any person who knowingly makes anyffilse statement, representation, or
certification in any application, record, report, pion, or other documentfiled or required to be maintained under this
Article nro rule implementing this Article. . .shall be guilty qjo Class 2 misdemeanor which may/ndudeo�nenot to
exceed ten thousand dollars�2�00�. '
Under penalty of law, I certify that(check all boxes to indicate your agreement):
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[�� | amthepersonresponsib|efortheconstructionacdvitiesofth)sproject, fnrsatisfyingtherequirementsofthis
permit, and for any civil or criminal penalties incurred due to violations of this permit.
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��' Theinfornna1ionsubmittedin1hisNO| is,tothebestofmyknoxv|edge and belief,true, accurate, and complete
based onmy inquiry of the person or persons who manage the system, or those persons directly responsible for
gathering the information.
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I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and Sediment Control
Plan.
��� if the approved Erosion and Sediment Control Plan 'is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of Part 11 of the
permit are met unthe project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under this
permit will constitute the p2rmit requirements for the discharge(s) and is enforceable in the same manner as an
individua| permit.
Project Name (must match A1o): -mn�jy \J'
Specific Lot Numbers (must match Alb):
Pennitteehnus�nro�ch82)� -T—�p~\/f^\i\\lyl«p^v`l' \ »+�
` ' I./ \ . � � ~y . . ,) � `J ��\ �_�-��
Legally Responsible Person (must match BJ& 83): cy,
Title of Legally Responsible Person (must match 83b):
Print Name &Title uf Signed ifAuthorized
Individual Differs from Legally Responsible Person:
_
Phone Number: �� '�? i�-7 / /
Signature of Legally Res, —|e 9 erson or Authorized Individual D/tc^
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* &hPQRTA0/7NOTE. This fbnnmustbesignedbyonc4ounsib6scorpuurteofficerthotowmsormpenotesrhoconstrucbonoctivity,
such as a president,secretary, treasurer, or vice president, or a manager that is authorized/n accordance with Part IV,Section B,
Item(6)qf the N[G020D00permit.