NCC190726_NOI Signed Certification_20190624

&J�~����1 Notice of UKlt��k�� (����k) «~K�r�`fica�~��M �Oy0N
Then, mail the original form to the NC DEMLR Stormwater Program at:
Print this form,complete,scan and upload to the electronic NOL
Division of Energy, Mineral &Land Resources Stormwater . .~s....
512 N.Salisbury Street,6 1h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
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PerNCGenero/J�otu�� 24]�1S �80tonypeoonw6okoow�gbmokesonyƒobp�totemen� rep/esenroov�
� ���bcmo��n�
� - /o �herohcumen�/x��or/eou
rce/��oobon/n any opp/�ot/un, /ocooi /opo/�p plan, .^~ ^.-- ���- -
/ »nderthb�/��6emro/u/rknp/emendngth�Art/dc. . . shall he guilty 4fo[�ss2m�demeonorw/h�hmay
- 6t nthousonddo0oo/
�nc/udeo�ncno��oexcoe e `. ,.
Uod
n�\Lyof|avv, | certify boxes to indicate your a8reement):
7--^�� di d\v\t\esofth\spngect
��' lamthepersonneponsib|eforthecnn/tru construction .for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
^~- i this tothebestc�myknow|edQeandbe|\e�true, accurate, and
�� Theinhurmationsubmitted » ' orthosePers»ns
| complete based onmy inquiry of the penonmrpmnony who manage the sy�em'
directly responsible for gathering the information.
^�xieU|abidebyaUounditionscfthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
Eel
if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution Prevention Plan)of the NCGO10000 General Permit, |will nonetheless ensure that all conditions uf
artUof the permitare met un the pn�ectaraxnmes.
J �h andun6emtundthat coverage under
��~ | herebynequestc»«e'a8e«» er th
e
this permit will constitute the permit requirements for the discharge(s)and is enforceable in the
same manner asan individual permit.
Legally Responsible Organizational E
* Legally Responsible Person:
Title of Legally Responsible Person:
Date:
Signature: » v
* 0MPOR7AN7Nu/c/ This form must""signed by~'~-,---' corporate officer
perates the
that is
���n��su��o����tv��� o�u� ���� �o��
authorized/n accordance with Part IV,Section 8, item(6)of the NCG01O00Dpermit.
! For more information on signatory requirements,see Part IV,SectionB, Item(6)of theNCG010000 permit.
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