NCC191588_NOI Signed Certification_20190827

NCG01 Notice ofIntent (NOU) Certification Form
Print this form, complete, scan and upload to the electronic N(
Then, mai|the original form tothe NCDEK8LRStonnwmterPnoAr
Division ofEnergy, Mineral & Land Resources StonnwaterPnzgt
512 N. Salisbury Street, 6`" Floor
1612 Mail Service Ceriter
Raleigh, NC2769g'1612
Per NCGeneral Statute 143-215.6B (i), any person who knowingly makes onyfulse statement, representation,
at, certification inany application, /erool/epm1 plot), o/other documentfiledu/required bcbemaintained
under this Article ororule itnp/ementingthis Article ... s6o8beguilty 4fuClass 2mbdemeonn/which may
include ofinenot tuexceed ten thousand dollars /$1Ll0OD/.
Under penaltynflaw, | certify that (check all boxes to indicate Your agreement):
Gl� I am the person responsib� 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 ofthis
permit
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ff� The information subm|tted in this NO| is, tothe best ofmy knovv|cdRc and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible forgathering ihe information.
��
�� | will abide 6yall conditions ufthe NCGO10000 General Permit and the appruveJErosiunand
Sedinient Control Plan.
Q If the approved Erosion and Sediment Control Plan isriot compliant with Part U (SionnwoterPoUution
Prevention Plan) of the | will nonetheless ensure that all conditions of
the permit are metonthe project aLall times.
Z-1erebynequestcovemge under the and undenstand thatcovom#o under
this permit will constitute the permit requirements tor the discharge(s) and is enforceable in the
same manner asanindividual permit.
Narne of Project:
Legally Responsible Organizational Entity:
*
Title ofLegally Responsible Person:
u
Sign a1ue: Dato� "
~VMPOR7A0TNOTE: 76bƒbrn must bc5igncdbypresponsible corporate officurthat owns nroperates the
construction activity, such as 0 preSidentsocretary, treasurer, or vice president, or a incirioger that is
For more information or) sk7noto/y/equirpments,see Port /V, Section L\dem&Joƒthe W[G0208OOpennit.