NCC193357_NOI Signed Certification_20200102

NO1 Notice of Intent (NI) Certification Form
Directions:
Print this form, cam piete, scan and upload to the electronic NO I_
Then, mail the original farm to the NC DEMLR Stormwater Program (with $100 check if paying by check) at-
Division of Energy, Mineral & land Resources Stormwater Program
512 N_ SeIisbury Street, Mtn Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
00 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68 (iJ, Dray person who knowingly makes ony false statement, representation,
or certification Fn any application, record, report, plan, or other documenr filed or required to be maintained
under this Article or o rule implementing this Article , . . shall be guilty of a Gass 2 misdemeanor which may
include a fine not to exceed tern rhousand dollars ($10,000),
Under pp nalty of law, I certify that (check all boxes to indicate your agreement}:
r� I am the person responsible for the construction activities of this project, for satisfying the
req uirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit,
The information submitted in this NOi is, to the best of my knowledge and belief, true, accurate, arid
complete based on my inquiry of the person ar persons who manage the system, or those persons
C�directly responsible for gathering the information,
I will abide by all condition-5 of the NC6010000 Genera I Permit and the approved Erosion and
Sediment Controi Plan.
If 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 all coed itions of
Part 11 of the permit are met on the project at all#laces.
I hereby request coverage under the NC0010000 General Permit and understa nd that coverage under
this permit will constitute the permit requirements for the discharge(s) a nd is enforceable in the
same manner as an individual permit. ff
Name of Project: 684 ai'7 �1 1 I1� _
Legally Responsible Organizational Entity: ._
Legally Respons€ble Person: V64 Arl ea 4f
T€tle of Legally Responsible Person; 70
*Signature, Date:
*Print Name and Title of Signet! if Authorized
—Individual Differs front Perrnittee- 14r
Phone dumber. L f
* I✓IU POR-rANT NOTE. This form must be sighted by o respon.5i:rle corporate officer that owns or operates the
construction activity, such as a president, secretory, treasurer, ur vice president, Ora manager that is
authorized in accordance with Parr IV, Section 8, item {6) of the NCCTO10000 permit.
For more information on signatory requirements,see Part IV, section 8, Item (6) of the NCG010000 permit.