NCC191765_NOI Signed Certification_20190925

NCGO1, Notice of Intent (NO�) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOII.
Then, mail the, origi nia I form to the INC DEM LR Stormwaiter Program (with $ 100 check if paying by check), at:
Division of Energy, Mineral Land Resources Stormwater Program
512 N. Salisbury Street, 6'h Floor
1612 Mail Service Center
Raleigh, INC 27699-1612
Per NC General Statute 143'-215,68(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 misderneanor which may
include aftne not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreeirri
S/ I aim 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,
F" The information submitted in this I 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 by all conditions of the hiCGO10000 Gqnet4l Pennft. and the approved Erosion and
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Sediment Control Plan,
L;K If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NOC.-X31.0000 Gieneral ilk rrnL�, I will nonetheless ensure that all conditions of
Part III of the permit are met on the project at all times.G?"'4 I hereby request coverage under the NC A01 ('000 Ge rwrg m 'i " and understand that coverage under
thiiis permit will constitute the permit requirements for the �dischairge(s) and is enforceable in the
same manner as ain individual 1permit.
Name of Projecv. m aA« i s & t e.,r (—C'Jr 't - % em
Legally Responsible Organizational Entity: S<—% V 'ba%j e-) v I "%- (—
* Legally Responsible Person; Tom 'bsK
Title of Legally R e r on: I T% 9 t If%(-% A % M-I-r 9-e O-N e L..?N
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Signature:
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*IMPORTANTNOTE: This form must be signed by aresponsible 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 MCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.