NCC192627_NOI Signed Certification_20191101

NCG01 Notice of intent (N00 Certification Form
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Directions:
Print this form,complete,sun and upload to the eleNronlic N01.
Then, mail the orlonal form to the NC DEMLR 5tormwater Program Iwtth$100 check if paying by check)at;
Division of Energy,Mlneral&Land Aesowtes Stornrwater Program
512 N.5aliabuty Street,a Floor(pffiae 640K)
1612 Mall Servloe Center
Raleigh, NC 27699-1612
DO NOT MJIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68(1), any person who knowingly makes any false statement rrpresentdtion,
or certification in any application, record,repot;Arlan, or other docurnentflled 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 afire not to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that(check all boxes PhAWeT 141"Frieors Plantation
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 vloiations of this
permit. XJ Flowers Finch Inc
The information submitted in this N01 Is,to the best of my knowledge and belief,true,accurate,and
complete based on my inquiry of the person or persons who Ian
�ge the system,or those persons
directly responsible for gathering the information. 0 ddtl FIne
I will abide by all conditions of the NCGO10000 General Peery it and the approved Erosion and
Sediment Control Plan. President
b—�1f the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit. I will nonetheless ensure that alt conditions of
Part 11 of the permit are met on the project at all times.
[ I hereby request coverage under the NCG010000 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.
?-1 les,A.� s lc � t
Name of Project: i� AeC, c�,tei
Legally Responsible Organizational Entity: 1 S [Vlr 1 �lG
Legally Responsible Person:
Title of Legally Responsible Person:
*Signature: Date:2
*Print Name and Title WSied Authorized
Individual Differs from Permittee.-
Phone Humber_---q�
* IMPORTANT NOTL 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 NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, item(6)of the NCGO10000 permit.