NCC190447_NOI Signed Certification_20190604

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NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6t" Floor'®
1612 Mail Service Center
Raleigh, NC 27699-1612 JUN 04 2019
DENR-LAND QUALITY
STORMWATER PERtv;ITTING
Per NC General Statute 143-215.6E (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 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.
X 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.
X I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
® If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
0 1 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 as an individual permit.
Narne of Project:
Fire Flow Improvements and Water Main Replacements Phase 2
Legally Responsible Organizational Entity: Roanoke Rapids Sanitary District
* Legally Responsible Person: R. Danieley Brown, PE
Title of Legally Responsible Person: CEO
Signature:
Date: 5i
* 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.

Hazen and Sawyer
498 Seventh Avenue, 11th Floor
New York, NY 10018 - 212.539.7000
June 4, 2019
NCDEMLR Stormwater Program
512 N. Salisbury Street, 6' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Re: Roanoke Rapids Sanitary District
Project ID HALIF-2018-004
Fire Flow Improvements and Water Main Replacement Phase 2
Hazen Job No. 31181-005
To whom it may concern:
Please find enclosed the original, signed NCGO1 Notice of Intent Certification Form for the Fire Flow
Improvements and Water Main Replacements Phase 2 project.
Please contact me at [phone] or at [e-mail] if you have any questions or
require additional information.
Sincerely,
;� fx-�
Ted Elshof
Assistant Engineer
hazenandsawyer.com