NCC190083_NOI Signed Certification_20190422

NCGOI, Notic�e of Intent (NOI) Certification Form
Directions:
Print this form,complete, scan and upload to the electronic NOI.
Then, mail the original form to the N:C DEMLR Stormwater Program ait:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61� Floor
1612 Mail Service Center
— Raleigh, NC27699-1612_
Per NC General Statute 143-215.6B(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 misdemeanor which may
include a fine not to exceed ten thousand dollars($10,000),.
Under penalty of law, l certify that(check all four 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 civll or criminal peri:allties Incurred due to violations of this
5( permit.
The, information submitted in this NCI is,to the best of my knowledge and belief,true, accurate, and
complete based on my inquiry of the per-son or persons who manage the system, or those persons
directly responsible for gathering the information.
I will abide by all condiflons of the NCGOI.0000 General Flegnit and the approved Erosion and
Sediment Control Plan,
If the approved Erosion and Sediment Control Plan is riot compliant with Part 11 (Storrnwater Pollution
Prevention Play'i)oftl,ieNCGO1000OGe"o-,-�e �.Permi t, l will nonetheless ensure that all conditions of
Part H of the peanut are met on the project at all times,
hereby request coverage under the NCGO10000 General Peer off and understand that coverage under
this permit will constitute the permit requirements for the discharges) and is enforceable in the
same manner as an inclivl&4 permit,
Legally Responsible Organizational Entity:
Legally Responsible Person: ml '(Ild
J
Signature: Date-
* IMPORTANT NOTE, This form 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 Part IV, Section B, Item (6)of the NCGO1 0000,permit.
For more information on signatory requirements, see Port IV,Section 8, Item (6)of the tVCGO10000 permit.