NCC190204_NOI Signed Certification_20190507

�����0�� ��m��� w�� Nm��m�m�� �����0� Certification �m�
w�����n�.� m����m��� m�m m��=~~°°� �m���m� �w�m �mmm���m���� Form
Print this form,complete,scan and upload to the electronic NOI.
Then,mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,6 th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-21I68(i), any person who knowingly makes onyfalse statement,representation,
or certification in any application, record,report,plan, or other documentfiled or required to be maintained
under this Article ororule implementingthis Article...shall be guilty ufm Class 2 misdemeanor which may
include mfive not hmokured ten thousand dollars/$1(I00O>.
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.
EZ 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.
R |will abide bv all conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
Kk If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)ofthe ���r��, |m/i|| nnnethe|essensurethata||conditimnsof
Part ||of the permit are met on the project at all times.
N- | hereby request coverage under the NCGO10000 General Permit and understand that coverage under
this pernnitvvU!constitute the permit nequinennentsfnrthedixcharge(s)and|s enforceable inthe
same manner aoan individual permit.
Legally Responsible Organizational Entity: ...................C.
Legally Responsible Persqn-.
Signature: Date. 5
*IMPORTANT NOTE., Thisform must be signed byo responsible corporate officer that owns or operates the
construction activity,such omo president,secretary,treasurer, orvice president,mrm manager that is
authorized in accordance with Part IV,SectionB, Item(6)mf the 8CGO1O00Qpermit.
For more information on signatory requirements,see Part IV,Section B, htem(6)of the NCG010000 permit.