NCC190695_NOI Corrected Certification Form_20190621

NCG01- Notice of Intend (N01) Certification form
Directlons-8
Print this farm, complete, scan and upload to the electronic NQI.
Then, mail the original form to the NC DEMLR 5tormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N . Salisbury Street, 6" Floor
1612 Mali Service Center
Raleigh, NC 27699-1512
Per NC General Statute .14,�-2IS. 6B (1), any person who knowingly makes and► false stoternent, repres�niaLian,
ar certyj9catiort in any applicatPvn, record,, repoM plan,, vt' oiher documeRt filed or requiFed to be maintain ed
under this Article or o rule rmpremen tin g this ►4rtfcle . . . shall be gu1!#y of a Class 2 misdemeanor which may
include o fine not to exceed ten thousand dollars ($10,000).
Under penalty of lbw, ! oerti#y that check all boxes to Indicate your agreement:
� i am the person responsible for the construttEan activities of this project, for satisfying the
requirements of this permit, and for any civil or c►iminai penalties incurred due to violations of this
permit.
figThe information submittedin this h101 is, to the best of my knowledge and belief true, accurate, and -
complete based an 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 NCG010400 Gene raf PerM it and tie apprvved erosion and
Sediment Control Plan.
9 If the approved Erosion and Sediment Control Phan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG0104a0 General Permit, l will nonetheless ensure that a11 conditions of
Part I of the permi# are met on the project at aI4 times.
Q 1 hereby request coverage under the NCGO1 Uen�at Permit, and understand that coverage under ,
this permit w+I i constitute the permit requirernents for the disch a rge(s) and is enforceable in the
same manner as an indjviduaE permit.
Name ofP�o;ect: � a c5 l %% sda%G. A � SEWWWMEMW�lc� � U �tC aM�C
Legally Responsible Organizational Entity: A So 1 v4 e. &lis4T v4 o
Lepliy Responsible Person:
Title. of Legally Res on5ible Person:
Signature : Date: j Vnr.
* 7
IMPO"AAM NOTE: This farm must be signed by o responsible corporate officer that owns or operates the
construction actlVTty, such as a presWent, secretary. treasurer, or vice president, or a manager that 1s . . _
ouxhorixed in accordance With Part IV, Section B.. Item (6) of the NCGD10f3U0 permit.
For more information 4n signatory requirements, see Part IV, Section S, hern (6) of the NC6010000 permit