HomeMy WebLinkAboutNCC191706_NOI Signed Certification_20190909NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
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, 6th floor
1612 Mail Service Center
Raleigh, INC 27699-1612
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false 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):
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 N01 is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or oersoos who manage the system; or those persons
directly responsible for gather -; "rr^_^6x,rauon.
Y I will abide by all condirons or -re NCG010000 General Permit and the aporoved Eros on and
Sediment Control Plan.
ERI If the approved Erosion a-c 1 -^ert C Pan I> not compllanr s s-— z-3rmniater Pollution
Prevent:or Pia^J of t',e NCG010000 General Permit, I will nonethes zonditrons of
—/ Part II of c,,-- e met on the project at
NCG010000 General Permit and and r,ra,c t a: overage under
c a dischargelsl and �s enforceaole =o tha
Name of Project: 6ZJMM"6 AiA< PilIEbE SA
Legally Responsible Organizational Entity: I"Cl IMOUn r'.6 DFyFl /3R� 17 LL C
* Legally Responsible Person: SGOTC Y xx
Title of Legally Responsi
Signature:
i
r r
IMPORTANT NOTE: 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 (5) of the NCG010000 permit.