NCC191852_NOI Signed Certification_20190913

Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources Stormw/aterProgram
512N.Salisbury Street, 6uFloor
1612 Mail Service Center
Raleigh, NC27699'1G12
Per NCGeneral Statute 24B-215,G8(i),any person who knowingly makes onyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required tobemaintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars /$1{\D0(U.
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.
N 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.
| will abide bvall conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan,
C0 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensu'rethat all conditions of
Part Uofthe permit are met onthe project atall times.
rP | 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 asanindividual permit.
Name ofProject:
Legally Responsible Organizational Entity:
*
Legally Responsible Peraon:
Title of Legally Responsible Person:
Signature:
ate:
*
IM9ORT4NTN0TE: This form must be signed byo 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.