NCC193026_NOI Signed Certification_20191210

NCGD1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, s an and upload to the electronic NOL
Then, mail the original form to the NC DEMLR StIrmwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury S1 reet, 61h Floor (Office 640K)
1612 M13il Service Center
Raleigh NC 27699-1612
DO NOT WL THIS FORM OR RAY ENT UNTIL YOUR APPLICATION HAS BEEN
IREVIEi� EI All CCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, pl n, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($ 0,000).
Under penalty of law, I certify that (check all boxes
2"-
1 am the person responsible for the constr
requirements of this permit, and for any c
permit.
The information submitted in this NOI is, t
complete based on my inquiry of the persi
directly responsible for gathering the infoi
I will abide by all conditions of the NCG011
Sediment Control Plan.
� /
L-
if the approved Erosion and Sediment Con
Prevention Plan) of the NCGO10000 Gener
Part 11 of the permit are met on the projec
1 hereby request coverage under the NCG(
this permit will constitute the permit requ
same manner as an individual permit.
indicate your agreement):
tion activities of this project, for satisfying the
or criminal penalties incurred due to violations of this
the best of my knowledge and belief, true, accurate, and
i or persons who manage the system, or those persons
cation.
and the approved Erosion and
rol Plan is riot compliant with Part II (Stormwater Pollution
I Permit, I will nonetheless ensure that all conditions of
at all times.
00 General Permit and understand that coverage under
ents for the discharge(s) and is enforceable in the
Name of Project: V-T-f Ml�[� Ski NI 1 AJ'`f �FWE-F 1NW6VC- "til;nr%1'
sible Organizational E
Ilv Responsible Pe
Title of Legally Respo sib
*Signature:
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: -70 - 888 -5Z 6O > 1 ok
* IMPORTANT NOTE. This form must be signed by a i
construction activity, such as a president, secretary,
authorized in accordance with Part iV, Section B, Ite
rC
Date: %Z - Z - Z
:ionsible corporate officer that owns or operates the
-asurer, or vice president, or a manager that is
(6) of the NCGO10000 permit.
For more information on signatory requirements, se� Port IV, Section B, Item (6) of the NCGO10000 permit,