NCC190077_NOI Signed Certification_20190419

NoticeCertification ti
Directions:
Print this form,complete,scan and upload to the electronic NOL
Then,mail the original form to the NC DEMLRStormwaer Program at:
Division of Energy, Mineral&Land Resources Storm water Program
12 N.Salisbury Street,6 th Floor
1612 Mail Service Center
Raleigh, NC 27 99-1612
Per NC General Statute 1 - 15a6 (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
under this Article or a rule implementing this Article° ° °shall be guilty of a Glass 2 misdemeanor which may
include a flue not to exceed ten thousand dollars( 1 , 00).
Under penalty of law, I certify that(check all four 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.
Ef 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,
will abide by all conditions of the IIWG01,0000 �,,,,,µiineraN IIPLq��mft and the approved Erosion and
Sediment Control Plan.
IV If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the tV G0100 L1�i�i�ienee ���all i''Ile liri lt, I will nonetheless ensure that all conditions of
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all times
Y q g _.I11 �,uu ......i ........ .l'��1H�„!and understand that coverage under
art o the permit are met on the ro ect at
I hereby request coverage under the Il�li �010
this permit will constitute the permit requirements for the discharge(s)and is enforceable in the
same manner as an individual permit,
Legally Responsible OrganizationalEntity:
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Legally Responsible Person: I
Signature: �,w
° �� Date:
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*IMPORTANTNOTE. This fora must be signed by a responsible corporate officer that owns or operates the
construction activity,such as a president,secretary, treasurer, or vice president,or a manager that is
authorized in accordance with Fart IV,Section B, Item(6)of the NCGO10000 permit,
For more information on signatory requirements,see Fart III,Section B, Item(6)of the NCG010000 permit.