HomeMy WebLinkAboutNCC190906_NOI Signed Certification_20190710 �
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NC\G01 Notice x^fIntent (NON) Certification Form
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 th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Print this form,complete,scan and upload to the electronic NOI.
Per NC General Statute 243-21I6B(J), any person who knowingly makes onyfalse statement, representation,
or certification in any application, record, report,plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article. . .shall be guilty ofo Class 2 misdemeanor which may _
include ofinenot to exceed ten thousand dollars/$2(I0O0/.
Under penalty of law, I certify that (checl(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.
[q 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.
5a |will abide by all conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
NJ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)ofthe NCGO10000 General Permit | will nonetheless ensure that all conditions of
Part ||nf the permit are met on the project at all times.
n6 | 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 asan individual permit.
NameofPnoject: / OdL
Legally Responsible Organizational Entity:
* Legally Responsible Person:
7----
Titleof
Signature: Date:
* /MPOR77UVTN0TE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity,such oso president,secretary, treasurer, or vice president,oro manager that is
authorized in accordance with Part IV,SeotionB, Item (6)of the NCGO10000permit.
For more information on signatory requirements,see Part IV,Section fL Item/61of the NC6O20UO0permit.