NCC191628_NOI Signed Certification_20190829

NCGOI, Notip of Intent (NOI) Certification Form
MEMUM
Print this form� complete, scan and upload to the electronic NOL
Then, mail the original form to the I C DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Ener W, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6 th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215,6B (I), any person who knowingly makes onyfialse statement, representation,
or certification in any application, rec d, report, plan, or other document filed or required to be maintained
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under this Article or a rule implementi g this Article shall be guilty of a Class 2 misdemeanor which may
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include affne not to exceed ten thousid dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
1x] I am the person responsible f r the'construction activities of this project, for satisfying the
requirements of this permit, nd for ainy civil or criminal penalties incurred due to violations of this
permit,
[Z The information submitted in this NOI is, to the best of my knowledge and belief, true, a,ccurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for ga�the ing the information,
Z I will! abide by all conditions athe KGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
E If the approved Erosion and S - diment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO 0000 General Permit, I willl nonetheless ensure that all conditions of
Part 11 of the permit are met n the project at all times.
E-1 I hereby request coverage un ier 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
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same manner as an indivicluaopermit.
Name of Project: Walkertown Mavis Tire
Legally Responsible Organizational E
* Legally Responsible Person: Jeff
Title of Legally Res po Person: Sen or Vice President gd1k(-
Signature:
Date: �41 q
*IMPORTANTNOTE. This form must beligried by a responsible corporate officer that owns or operates the
construction activity, such as a preside tsecretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, ection 8, Item (6) of the NCGO10000 permit,
For more information on signatory reqqirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit,