NCC192080_NOI Signed Certification_20191002

NC)GO1 Notice of Intent (NOI) Certification Form
Print this form, complete, scan and upload to the electronic NOL
'Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ufEnergy, Mineral & Land ResourcesStomnwater Program
512 N. Salisbury Street, 6m Floor (Office 640K)
I613Mail Service Center
Raleigh, NC27699-1512
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per W[Genero/Stotute 143-215.68 (1), any person who knowingly makes anyfalse statement, representation,
orcertification /nany application, record, report, plan, orother obcurnemtfiledorrequired tu6emaintained
under this Article o/orule implementing this Article, . . shall beguilty ofoClass 2misdemeanor which may
include ofine not to exceed ten thousand dollars /$1D,DQQ/,
Under penalty of law, I certify that (check all boxes to indicate your agreement)�
f]~~ I am the person responsible for the construction activities of this project, forsatisfying 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 forgathering the information.
| will abide byall conditions ofthe and the approved Erosion and
Sediment Control Plan.
LJ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the , | will nonetheless ensure that all conditions of
Part|| of the permit are met on the projectat all times,
| hereby request coverage Linder the NCG01 0000 Genef al Perrnit 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,
Legally Responsible Organizational Entity:
Legally Responsible Person:
Title of Legally Responsible Person:
, Individual Differs from Permittee:
Phone Number: 'yJ
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