NCC190079_NOI Signed Certification_20190422

NCGO1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
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
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 four boxes to indicate your agreement):
NJ I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civill or criminal penalties incurred due to violations of this
permit.
* The information submitted in this 1\101 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 systern, or those persons
directly responsible for gathering the information.
* I will abide by all conditions of the NCG01.00100 Genera� Pernljt and the approved Erosion and
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Sediment Control Plan.
* If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the WG0 100 00 11 Gene� r.'rZfl f
__ r jt, I will nonetheless ensure that all conditions of
..........
Part ll of the permit are met on the project at all times.
* I hereby request coverage bander the NCG010000 General Pernnit 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.
Legally Responsible Organizational Entity: Beaufart-Morehead City Airport Authority
Legally Respo le Person: Renee Rogers
Signature: Date:
* IMPORTANT NOTE: This form 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 Part IV,Section B, Item (6)of the NCGO10000 permit.
For more,information on signatory requirements, see Part IV,Section B, Item (6)of the NCGO10000 permit.