NCC191365_NOI Signed Certification_20190823

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Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMiLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6"' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under Denalty of law, I certify that (check all boxes to indicate your agreement):
lV- I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, aind for any civil or criminal penalties iIncurred due to violations of this
permit.
The information submitted in this W 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,.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Ptirr Ldt, 1: will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
INK I hereby request coverage under the NCG010000 General P " ernift and understand that coverage under
this permit wild constitute the permit requirements for the discharges) and is enforceable in the
same manner as an individual permit.
Name of Project: `;on 9D
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Legally Responsible OIrga in izatio nail Entity:--Z&/�'/�
Legally Responsible Persom,
Title of Legally Responsible rson: ru
Signature: Date:
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (5) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section 3, Item (6) of the NCGO10000 permit.