NCC190252_NOI Signed Certification_20190510

NCGO1 Notice of Intent (NOU) Certification Form
Directions-
Print this form, complete,scan and upload to the electronic NO1.
Then, mail the original form to the INIC 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
PerN[Genenn/Stotute143'325.68(i), onypersonwhoknowinglynnzkesonyfabestotement, representotion
or certification in any application, record, report,plan, mother document/ledmrequired to be maintained
under this Article oro rule implementing this Article. . .shall be guilty ofo Class J misdemeanor which may
include o fine not to exceed ten thousand dollars/$20,000/.
Under penalty of law, I certify that(check all four boxes to indicate your agreement):
KI 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.
DO 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.
OD | will abide by all conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
@O If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 GeneralPermit |will nonetheless ensure that all conditions of
Part || of the permit are met on the project at all times.
91 | 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 asan individual permit.
Legally Responsible Organizational Entity: GwanobomGo|ur. LLC
* LegallyJonathan
-10-2019
Date: 05
*IMPOR7407NOTE: 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 8' Item(6)oƒthe NC6020000permit.