NCC191837_NOI Signed Certification_20190913

NCGO1 Notice of Intent (N01) Certification Form
Division ofEnergy, Mineral & Land Resources StonnwaterProgram
512N. Salisbury Street, GmFloor
1612Mail Service Center
Per NC General Statute243-215.6B (i), any person who knowingly makes any false statement, representation,
mcertification inany application, record, report, plan, orother documentfiledmrequired to be maintained
under this Article nrorule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars /$10,0D0/.
Under penalty oflaw, | certify that (check all boxes toindicate your a0reemend:
1 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 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.
�
o | will abide byall conditions oƒthe and the approved Erosion and
Sediment Control Plan.
�
c� if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGO1.0000 Genera� Per it | will nonetheless ensure that all conditions nf
Part ||ofthe permit are met onthe project atall times.
/
[� | hereby request coverage under the and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asamindividual permit.
Name ufProject:
Legally Responsible Organizational Entity:
� Legally Responsible Person:
Title ofLegally Responsible Pp*nn: O
*IMPORTANT NOTE/ Thisform must be signed by a responsible corporate officer that owns or operates the
construction activity, such osopresident, secretary, treasurer, or vice president, or manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information oosignatory requirements, see Part IV, Section B,Item (6) of the NCGO10000 permit.