NCC191730_NOI Signed Certification_20190906

NCG01 Notice of Intent (N01) Certification Form
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLIR Stormwater Program at:
Division of Energy, Mineral & Land ResourcesStormvvater Program
S1ZN.Salisbury Street, 61hFloor
161ZMail Service Center
Raleigh, NC 27699-1612
Per 0CGeneral Statute 243-225,6O(i), any person who knowingly makes onyfulsestatement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article nrorule implementing this Article ... shall beguilty ofoClass 2misdemeanor which may
include o/inenot tmexceed ten thousand dollars /$2(I0001.
Under Penalty of lavi, I certtify that (check all boxes to indicate your agreement):
/anl-thepersonresponsib|afortheconstnucbonactivbesnfthisproject for satisfying the
'= requirementsofthisperrnit,andforanycivi|orcrimina|pena|tieoincurredduetovio)ationsofthis
permit.
The information submitted in -this NO! is, tothe best ofmy knowledge and belief,. true, accurate and
( complete based onmyinquiry oftheperson orpersons vvhornana8e�hesystem,orthose persons
directly responsible for gathehn8the information.
| will abide by -all conditions ofthe KGO10000 General Permit and the approved Erosion and
( SedirnentContro| Plan.
If 'the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
' Prevention Plan) of -the NCG010000 General Permit| will nonetheless ensure that all conditions of
Part Hofthe permit are met on -the project atall times.
\ hereby request coverage under the NCGO10000 General Permit and understand that coverage under
/ this permit will constitutethe permit requirements for the discharge(s) and is enforceable in the
same manner asanindividual permit.
�Legally Responsible Person:
Title of Legally Responsible Person: 2 e_vek-b OTI
Signature:
ate:
IMPORTANT NOTE: This form must be signed byoresponsible corporate officer that owns or operates the
construction activity, such oso president,secretary, treasurer, orvice president,oromanager that is
authorized inaccordance with Part IV, Section B,Item (6) of the NOGO2000Opermit.
For more information nnsignatory requirements, see Part IV, Section B, Item (6) of theNCGO10000 permit.