NCC192117_NOI Signed Certification_20191216

NC 01 Notice of Intent (NO[) Certification Form
Directions;
Print this, form, complete, scan and upioad to the electronic N01.
Then, mail the OFIgIFIAI (UFM to the NC MMI.Ft Stormwater f mgram (with 5100 check I paging by died) at -
Move n of Energy, Mlnei-aI & Land Resources 510rmwater Program
512 N Soiisbury Street. W" Froor (office 640K)
1612 Mail Sv"trE! Contat
Raleigh, NC 27699.1512
00 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPU CATI ON HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC Gerrer,ai 3totvre 143- 215,69 10, ony person who knowingFy makes any fake stafenre&representaliarr,
or certificnrion on any appitcnriom record, report. piran. or other a�ac[rment {ifed or required re be rnainzolned
under this Ankle nr n rule implerr entinq f hi16- Article - - . shall he gin fttr of a Gass 2 misdenkmonar which may
include a fine not to exceed ten rhousand dollars
Urmi t POMAlty Cd 1AW, t LIgT ty that J&.wk all b xr� to Indicate y0ty agreement).
I am the rsan rpgmnsibir for the ainstrti ill art;0 ies of thk pro)eM for satIstonxg the
qui remenLi. of t his permit, and for any inwi or rriminal pvnaHw,, s Inctu-red due to yi tims of this
permit -
The IntorrnaitIon submltted in thfs NO is, to the Est of my knowWge and belief, true. witucat tl, znd
complete teased on my ingWryof the person or persons who manage the system, or thole pedant
dimly rerPnrl7,ible Far gathenng the information,
I t wj11 ahidv by at1 condat' om of the NCGn1QWQ General Permit arW the approved f resion and
Sediment Cnntm] Plan.
1 #f the ! aWroved Fir asion and Sediment Cyril" Plan v. nat romploant with p,jrt 11(Starrnw3ter Pollution
Pre wen tion Plan) of The NCGQ1=Q Qv ter;�� Pr�r.R}�3, t will non ert hPlPt7, wlsurr that al l cand0 ;ns of
Part 11 of the permit are met on the proje a of a4l tlme-r,.
C t hereby request coverage under the KWIM00 G Lneral ptrmi and undferAand that coverage under
1-his permit wt11 rnrestrtute tlie permit mqultmrer #s for the difchaw(s) and is entorceablrt in 11ty
same mariner a% an individual permit.
Name Of P+uject. 1< 14 1'�' *:j it j&q ,Z jzcw
Legally Res Phnrnsible prg;�ni€atlonal Entity" A,41= , } p� SCa • .. _
Legally Respon3ihle Per�an� �,` L, a - + u ' ,� ra k'- T
Titte of Legah Responslhde Person: it ul nl it tL
*%iFnature- 'J4-
' Vnnl Name and ! itle of Signed 11 Auncod7M
fin vidual Di ra from Permittee:
Phone Numbers 10 - .A` # 7
' IM RTANTIYOTE.' the
constmr ico acriwry. suc* os o presfden r, s ecrerory, treasurer; or vice p resideof, or o rr apager rho r is
au thari;wd in arrordrmrF with Part ill Section tl, Item (6) of the NCG010000 permir.
For more rnf rroorion on Part W, kcuon 8, item f6j of the NCW1 COW permrr