NCC191679_NOI Signed Certification_20190903

NCG01 Notice of Intent (N01) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form tothe N[ DEK4LRStormvvoterProgram at:
Division ofEnergy, Mineral 8'Land Resources 5tonnvvaterProgram
G12N.Salisbury Street, 6mFloor
1612 Mail Service Center
Raleigh, NC27699-1612
Per NCGeneral Statute143-215.6B (i)any person who knowingly makes anyfalse statement, representation,
orcertification /nany application, record, report, plan, orother docun7entƒ&edorrequired tobemaintained
under this Article orurule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars /$18ODO/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
|amnthe person responsible for the construction activities ofthis project, forsatbfvingthe
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
It *v 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.
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| will abide bvall conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
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VK If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit | will nonetheless ensure that all conditions of
Part 1|ofthe permit are met onthe project atall times.
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LK ( 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 as an individual permit.
Name of Project:
Legally Responsible Organizational Entity:
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* Le8a|k/Reaponsib|e Person:
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Title ufLegally Responsible Person:
ate:
IMPORTANT NOTE. Thisformmust besigned bvo responsible corporate officer that owns uroperates 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 (6) of the NCGO1 0000 permit.
For more information onsignatory requirements, see Part IV, Section B,Item (6)ofthe /V[G020DODpermit.