NCC191717_NOI Signed Certification_20190917

NCG01 Notice of Intent (1401) Certification Form
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Storm water Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormy ater Program
512 N. Salisbury Street, 61' Floor
1612 Mail Service Center
or certification in any application, record, repoM plan, or other documentfiled 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 ail 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.
X 'The information Submitted on this N01 is, to the best of my knowledge and belief, true, accurate, and
cornplete based on my inquiry of the person or persons who rnanage the system, or those persons
directly responsible for gathering the inforrnation.
X l will abide by all conditions, of the NCG010000 Generai Perrnt. and the approved Erosion and
Sediment Control Plan.
I 9f the approved Erosion and Sediment Control Plan is not compliant with Part H (Stormwater Pollution
Prevention Plan) of the NCG010000 Gen raj Pff-IM it I wdl nonetheless ensure that all conditions of
,
Part H of the permit are met on the project at all tie-nes.
,X I hereby request coverage under the NC"G010000 General Pennit and understancl that coverage under
this permit will constitute the permit reqUirernents for the discharge(s) and is enforceable in the
sarne manner as an individual permit,
Name of Project: Lynndale East Subdivision/Meridian Design/Build of NC LLC
Legally Responsible Organizational Entity: Gary B Whaley -1
Legally Responsible Person: Gary B Whaley
Title of Legally Responsible Person: President/Owner
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IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretory, treasurer, or vice president, or a manager that is
outhorized in accordance with Port IV, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.