NCC193143_NOI Signed Certification_20191227

NCGO1 Notice
of Intent (NOU) Certification
Form
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NCDEM0StormwaterProgram (with $100check if paying by check) at:
Division of Energy, Mineral & Land ResourcesStormvvator Program
512N.Salisbury Street, 6mFloor (Office 640K)
1612 Mail Service Center
Raleigh, NC%7G99-161I
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEJ
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute /43-215.6801any person who knowingly makes onyfalsestatement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementingthis Article ... shall beguilty ofoClass 2misdemeanor which may
include ofine not toexceed ten thousand dollars /$1L\D8U>.
Under penaltyoflaw, | certify that (check all boxes toindicate your a8reemoend:
kJ~ |amthe person responsible for the construction activities ofthis project, fnrsabsfvngthe
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
Q-'Theinfonnadonsubnnitted|nthisN0is,tnthebes1mfmyknovv|edgeandbdief,true,acmunate,and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
a' |xvi||abidebya||conditionsofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
k?~ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) Vfthe NCGO10000 General Permit | will nonetheless ensure that all conditions mf
art ||ofthe permit are met onthe project uta||timea.
|hereby 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.
Legally Responsible Organizational Entity: V—) A- D-Q�p 1;J CY) &- rs Ll�—C—
Title of Legally Responsible Person:
*Signature: Date: 10
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
*I8*/ORT4NTNOTI. This form must besigned by responsible corporate officer that owns oroperates the
construction activity, such asopresident, secretary, treasurer, or vice president,oromanager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information nnsignatory requirements,aeePorf/\(Jectiunf[/henn(6)ofbheN[G01O000penn/t