NCC192540_NOI Signed Certification_20191031

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
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 of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street,.6`h Floor (Office 640K)
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 6B-(ij, 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 pePalty 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
re .cements of this permit, and for any civil or criminal penalties incurred due to violations of -this
rmit.
The information submitted-in-this-NOI is, tothebest-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
erectly responsible for gathering the information.
VI'dI will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
dement Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Zrt
ention Plan) of the NCGO10000 General Permit. I will nonetheless ensure that all conditions of
II of -the permit are met on the project at all times.
eby 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 as an individual permit.
Name of Project: Wd �Wa
Legally. Responsible Organizational Entity,: �QYd S YG(G� r VIC
Legally Responsible Person:
Title of Legally Responsible Person:
*Signature: / Date:
*Print Name d Title of Signed if Authorized
Indivi Differs from Permittee:
Phone Number:
* IMPORTANT OTE. 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. l.V,.Section. B,. Item. (6). of. the_ NCG01QQQ0 permit_
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.