NCC191978_NOI Signed Certification_20190925

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 of Energy,Mineral & Land Resources StonnwoterProgram
512 N. Salisbury Street, 6" Floor (Office 64OK)
1612Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per WCGeneral Statute 243-225.68(i)any person who knowingly makes onyfalsestatement, representation,
or certification in any application, record, report, plan, or other documentfiledor required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2misdemeanor which may
include ofine not toexceed ten thousand dollars /$1<lO0[U.
Under penalty oflaw, /certify that (check all boxes to indicate your agreement):
0� I am the person responsible fo r 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 inthis NO|is, tothe best ofnyknowledge 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 6vall conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
?Z If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Pei rnit, ( will nonetheless ensure that all conditions of
Part |iofthe permit are met onthe project atall times.
| hereby request coverage under the CGO10000 General Permit and understand that coverage under
thbpernoitvviUconstitute the pernnkrequirennentsfor the discharge(s)and iaenforceable inthe
same manner asanindividual permit.
Name of Project: L
Legally Responsible Organizational Entity:
Legally Responsible Person:
Title of Legally Responsible Person:
*Print Name and Title of Signed /yAuthorized Individual
Differs from Permittee:
Phone Number:
IMPORTANT NOTE: Thisform 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 Port IV, Section fl Item (6) of the NDG020000penn/t.
For more information on signatory requirements, see Part IV, Section B,htem (6) of the NCGO10000 permit.