NCC191255_NOI Signed Certification_20190808

NCGO1 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Re»ourcesStornnvvater Program
512N.Salisbury Street, 6mFloor
1612Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute243-225.6B (i),cny person who knowingly mmkescnyfalse statement, representation,
or certification in any application, record, report, plan, orother documenttledmrequired tobemaintained
under this Article urorule implementing this Article ... shall beguilty ufoClass 2misdemeanor which may
include ofine not toexceed ten thousand dollars ($10,000).
Under penalty oflaw, Icertify that (check all boxes toindicate your agreement):
93 1 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.
III-" 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.
b�~ |vviUabide byall conditions ofthe NCG010000 General Permit and the approved Erosion and
d Control Plan.
,,,--"-Sediment
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions of
Part Uofthe permit are met onthe project atall times.
8- | 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 asanindividual permit.
Name ofProject: &44M&J AIA / 71A / C, - /X /C
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* Legally Responsible Person:
Title of Legally Responsible Person:
Signature:
*IMPORTANT 0OTE.-Dhisformmust be signed byoresponsible corporate officer that owns or operates the
construction activity, such osopresident, secretory, treasurer, orvice president, oromanager that is
authorized /naccordance with Part IV, Section 8,Item (6)ufthe yJCG0108D0permit.
For more information on signatory requirements, see Part IV, Section B, Item @1ofthe N[G0D000permit.