NCC190498_NOI Signed Certification_20190605

14CGO1 Notice of Intent (NOI) Certification Forni
Nrecflons.,
Print this form, complete,scan and upload to the electronic NOL
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'h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.6B(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 0 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 bo)(es to irdicate your agreernerit):
am the person responsible for the construction activities of this project,for satisfying the
requirements of thIs perrnit,and for any civil or,criminai penalties incurred due to violations of tHs
permit.
PY"' The information submitted In this NOI is,to the best of rny knowledge and belief,true, accurate,and
complete based on my inquiry of the persorr or persons who manage the system,or those persons
6rectly respormble for gathering the Information,
I wiih abide by all conclitrons of the lrq(.(„r'03.01000 Genem IPerrilslur„and the approved Eroslon and
Sediment Control Plan,
2K" If the approved Erosion and Sediment Control Plan Is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)of the NCGO10000 Geineral Illeirmit, ll will noneflreless ensure that all conditions of
Part 11 of the permit are rnet on the projoct at all thnes.
1 hereby request coverage under the NCGO10000 G,ne al flei tni� and understand that coverage under
this permit Will constitute the permit requirernentsfor the dIscharge(s)and is enforceable In the
sarne manner as an individual permit,
Name of Project:
Legally Responsible Organizational Entlty: ;U
Legally Responsible Person: irk -6r,it
W) A A
Title of Legally Resp lble rP,,erson: 140clut V
Signature:
Date:
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 it/,Section 8, Item(6)of the NCGO10000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCGO10000 permit.