NCC190230_NOI Signed Certification_20190509

NCG01 Notice of Intent (N01) Certification Form
Print this form, complete,scan and upload to the electronic NOL
Then, mail the original form to the NC DEML.R Stormwater Program at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N. Salisbury Street, 6 1h Floor
1612 Mail Service Center
Raleigh, NC
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 documentfiled or required to be maintained
under this Article or a rule implementing this Article . . . shall be guilty of a Closs 2 misdemeanor which may
include u fine not to exceed ten thousand dollars/$1(lDD0/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
| am the person responsible for the construction activities of this project, for satisfying the
X requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
The inforrnation 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,
I will abide by all conditions of the 1N(.1'.G..01..1.010.00 Genetall"Peri-nit and the approved Erosion and
/ Sediment Control Plan.
|f the approved Erosion and Sediment Control Plan is not compliant with Part || (S1ormvvaterPollution
/ Prevention Plan) ofthe WG01.0000 Generall)�rr ii , | will nonetheless ensure that all conditions of
Part || of the permit are met on the project at all times.
| hereby request coverage tinder the N[�}1( 0DOO_G�D�[J_p�I�L and Understand-that hat coverage tinder
/ this pert-nit willconstitute the permii requirementsforthe discharge(s) and is enforceable in the
same mannerasan individual permit.
Name of Project:
Legally Responsible Organizational Entity:
* Legally Responsible Person:
Title of Legally Responsible Person:
Signature: Date:
* IMPORTANT NOTE: Thisform 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 monoger that is
authorized/n accordance with Part IV, Section 8, Item /61of the NCGO2D00Dpermit.
For more information on signatory requirements, see Port IV, Section B, Item/61of the yJ[5D200ODpermit.