NCC192121_NOI Signed Certification_20191007

Print this form, complete, scan and upload to the electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StonnvvaterProgram
512N.Salisbury Street, 61hFloor (Office 64OK>
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6001any person who knowingly makes anyfalseatatement, representation,
orcertification /nany application,recordneport,pkxn,orotherdooun7entfikedorrequiredtoben7ointoined
under this Article ororule implementingthis Article ... shall beguilty ofoClass 2misdemeanor which may
include o/nenot toexceed ten thousand dollars ($10,000).
Under penaltyoflaw, | certify that (check all boxes toindicate your aQreemend:
U� I am the person responsible for the construction activities of this project, for satisfying the
requirements ofthis permit, and for any civil orcriminal penalties incurred due toviolations ofthis
pennb.
The information submitted in this NO| is, tuthe best ofnoyknowledge 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.
L� | will abide bvall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
U� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit, | will nonetheless ensure that all conditions of
Part ||ufthe permit are met onthe project otall times.
L� | hereby request coverage under the NCGO10000 General 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: LA 5 Q'I �� f, S- kI 5+'+".'
- Legally Responsible Organizational Entity:- e Uet e64r,'(_
Title of Legally Respopsible Person: 4) f
*Signature: \J Date: I
*Print Name and Title of gigned if Authorized
Individual Differs from Permittee:
Phone Number: I} /\ =_���� —1 _ /7
*8MPORTANTN0TE/7his form must besigned bxo 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 Part IV, Section B,Item (6) of the NCGO2000Dpermit.
For more information onsignatory requirements, see Part IV, Section B,Item (6)ofthe /V[G010ODUpermit.