NCC191652_NOI Signed Certification_20190903

NCG01 Notice of Intent (N01) Cert,ificairm
Print this form, complete, scan and upload to the electronic NO1.
Then, mail the original form, to the NC DEMLR Stormwater Program (with, $100 check if paying by check) at:
Division of Energy, 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 onyfolse 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 penalty of law, I certify that (check all boxes to indicate your agreement):
EV I 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.
The information submitted in this NOl 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,
54""' 1 will abide by all conditions of the N C�.G010000 Generai 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 egjgnit , 1! will nonetheless ensure that all conditions of
Part H of the permit are met on the project at all times,
r7�'Xl hereby request coverage under the ' NCiGO1000 " 0 "- General Permit ' and understand that coverage under
this permit will constitute the permit requirements for the fflscharge(s) and is enforceable in the
same manner as an individual permit.
I T-\ ciiA 6�
C'0N-'r12 AC;T
Name of Project: LrI I
Legally Responsible Organizational Entity:
* Legally Responsible Person: W) &Y Y t'n V)DID'A
Title of Legally Responsible Person:
Signature:
ME
IMP' ORTANTNOTE. 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 (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.