NCC192072_NOI Signed Certification_20191002

NCG01 Notice of Intent (N01) Certification Form
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 SturmwaterProgram
512N.Salisbury Street, E/^Floor (Office 64OK)
161JMail Service Center
Raleigh, NC276yy-161Z
DO NOT MAIL'11-111S FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NIGeneral Statute 143-225.6B(i), any person who knowingly makes onyfalsestatement, representation,
or certification in any application, record, report, plan, or other documentfiled or required tobemaintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not toexceed ten thousand dollars /$2(l0O01.
Under penalty of law, I certify that (check all 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.
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.
| will abide by all conditions ofthe NCGO10000 General Perrnit and the approved Erosion and
Sediment Control Plan.
r�
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCGOI.0000 General Perrrfit, | will nonetheless ensure that all conditions of
Part |!ofthe permit are met onthe project atall times.
| hereby request coverage under the NCG010000 GeneraI Permit 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.
Name of Project: C "I e-
Legally Responsible Person:
Title of Legally Responsible Person: (,,,,,> �,_) 1 e v-
~5| at
*Print Name a
Title of Signed if Authorized
—Individual Differs from Permittee:
Phone Number: �3 3&- -3 �"� E)-o �c�"' --f
Date: 9~'2, 5-/
*0WPDRTAKTNOTE.This form must be signed bmoresponsible corporate officer that owns moperates 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 NCGO10000 permit,
For more information on signatory requirements, see Part IV, Section B, Item(6) of thcNCGO10000 permit.