NCC190375_NOI Signed Certification_20190524

NcGoi Notice Uf intent (1,404 Cetbricadot, Fort'r,
Print this form,complete,scan and upload to the electronic NQ,
Then,mail the original form to the NC EMLR'Stour water Program at:
Division of Energy,Mineral&Land Resources Stormwater Program
512 N,Salisbury Street,6*Floor
1612 Mail Service Center
Raleigh,NC27699-1612
Per NC General Statute 143-215.69(i),any person who knowingly makes any false statement,representation,
Or wrt'TIC06011 In any Opplication,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 Class 2 misdemeanor which may
include affne not to exceed ten thousand dollars($10,0w).
Vnder 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.
tA The information submitted in this NO[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 NCOQ10000 Qgnpral Perff�jt and the.approved Erosion and
Sediment Control Plan.
if the approved Erosion and Sediment Control Plan Is not compliant with Part It(Stormwater Pollution
Prevention Plan)of the i L!40 I will nonetheless ensure that all conditions of
Part It of the permit are met on the project at all times.
I hereby request coverage under the N,�Pq
J,Pf sr it and understand that coverage under
this permit will constitute thepermit requirements forthe discharge(s)and is enforceable in the
same manner as an individual permit.
Name of Project:
Legally Responsible Organizational Entity:
L* ally Responsible Person:
-title of Legally Responsible Person:
27)
Signature:
Date-
*0MPVRrANTN0r0 This form must be signed by a responsible corporate officer that owns or Operates the
construction activity,such as a president secretaM treasurer,or vke president,or a manager that is
authorized in accordance with Part IV,section B,Item(6) fthe ,NCG01 p rmit.
0 9000 a
For more Information on signatory requirements,see Part IV,SmtJon 8,Item(6)of the NCG010000 permit.
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