NCC190818_NOI Signed Certification_20190702

NCGO1 Notice of intent (N01) Certification Form
DIrections:
Print this fOfm, complete, %can and upload to the elect ronlc NOL
Then, maff the original form to the NC DhMLA Stormwater Pfograrn at
Division of Energy, Mineral & Land Resources StOrmwater Program
51.2 N. Salisbury Street, GlhFloor
1612 MAII Service centpr
Riflulgli, NC 27699,1612
FerfXCeneraiSrotute 143-215,fifi (1), any person who knowingly nrjvkt.s onylohe, oaternerl'
t reptirsenfarlon,
arceft1flcutlonIncony P karion, recotid, repori, plan, or of lwr docurrien r filed at required f o be multi taltied
under this Ticic Oro 1 e JmPirmentinu Oil; ArfUe. .11101/ be vulffiv of a Closs 2 misderneuvor Which "lay
Ae
Include a fine not to exceed ten thousand dallars j0000).
Under.penalty of law, i certify that (chuck all boxes to indicate your t1. reef ent):
'K n
[Ef I am the pervert responsible for the construction activitlet of thl$ project, for skxtr�Jyjng the
requirements of this permit, and (or any civil Qrr (Arnhial penalties incurred due tea vlolativro. of this
permit
Er The information submittod In this N01 Is, to tile best of my knowledge and bellet, true ,1cck1lj'I P
,,1t , jfjcl
complete based on my Inquiry of the pt!r5on or pet som who rnan4)Be !lie w'stem, or thow PC r5ons
directly responsible for Satberl ng the Information,
I will abide by all conditions of the ftM'
QML�iW4Ll�QUJJ�J 66d (lie approved frosion and
Sediment Control Plan,
9 If the bppfoved Eroslon and Stdiment 6ntroi Plan is not CoMpliant with Pait It (Stormwater Pollu;l()n
Prevention Plan) of thiL- fgChip UIVE twill - "Miffy thAt 4111 co1 d.! I of
Pan it of the permit are met cm t4f,- project at all flmvs;
I hereby request Covo(age widor tine and tiodurs.tillitf 11,41 covVolic under
thls permit will wngltut.v thu perinit requirements (or the disc4arliv1s) and lwenfolccilbleln the
same manner as'jri individual peftnit
Name Of Project:
Legally Responslole Organliational Ervtlty� I-w _EJ—
:._ �, fa" d
Legally Responsible Person:
71fle of Legally Responsible Person:
signatVire.
MPIPORMA/r NOTE; This furns m4w ijrNl(i(ledbyofcf)(Illsil)iecOrP()tutcviticerttial,owfiA ter operdic5 the
Construction activity, UVW"'Tr,
authotrieLf in arrDrdancp with Part Jil Serl lon & Item (6) p/ r1it. NcG0100(X) pe,1,11j,
For more infoinmajon on signawy requirements, see Port IV, Sof tjj)p 11, lierr, (6) of the 1NCG0JQW permit.