NCC241193_NOI Signed Certification_20240417

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NO|.
Then,mail the original form u`the NC DEK8LRSto,mwate,Program(with$12O check if paying bycheck)
at:
Division ofEnergy,Mineral&Land Resources Stormwate,Program
51IN.Salisbury Street,6~Floor(Office 84OK)
16lJ Mail Service Center
Raleigh,Ncz7699-l61I
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL)[40 CFR122'32=d
Per NC General Statute 143-215.6B(i),any person who knowingly makes anyfalse statement,representation,or
certification in any application,record,report,plan,or other dommentfile o,required tnbr maintained under this
Article o,o rule implementing this Article.. .shall be guilty ofo Class 3 misdemeanor which may include ofinp not to
exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes to indicate your agreement).-
Iamthepersonnsponoib|efo,theconstructionactixitiesofthispn4ectfo,sotisfyinQthcrequinementsnfthis
permit,and for any civil or criminal penalties incurred due to violations of this permit.
N] The information submitted in this NO[ 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,orthose persons directly responsible for
gathering the information,
UU I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control
7�
Plan.
yU If the approved Erosion and Sediment Control Plan is not compliant with Part 11(Stormwater Pollution
' \ Prevention Plan)of the NCG01.0000 General Permit,I will nonetheless ensure that all conditions of Part 11 of the
permit are met on the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understand that coverage under this
permit will constitute the permit requirements for the discharge(s)and is enforceable in the same manner as an
individual permit.
Project Name(must match/Uo): ~-['w'iz S Q 4— 4-�`� f-C44/'c7~\
Specific Lot Numbers(must match A2b):
~ � _�
pe,m�tee(must n`o�h8z). ����4'�^
Lega||vRespondb|ePpmnn(mustmotch82&B3): A/I%dk'/«^—)
��
Title of Legally Respondb|ePp�nn(must mo� .
, '
match av"NC�c\e.^'
u
Print Name&Title of Signed ifAuthorized
Individual Differs from Legally Responsible Person:
Phone Number:
3ignatur�of���a||yRe,ponoib|e Per-son orAutho,izedIndividual / /Datn
^ mxpOmnomrmmre rnis/onnnnust be signed avo responsible corporate officerthat owns v,operates the construction activity,
such uoo president,secretary,treasurer,o,vice president,o,o manager that is authorized m accordance with Part IV,SezoonB,
Item kVvy the wcsO1 0000permit