NCC200120_NOI Signed Certification_20200113

NCGQ1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NO1.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if Paying by check] at:
Division of Energy, Mineral & Land Resources Stormwa ter Program
512 N_ Salisbury Street, 6"1 Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AN ❑ ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representarion,
Of Certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article .. , shall be guilty of a Ciass 2 misdemeanor which may
include a fine not to exceed ter, thousand dollars (S1o,000).
Under penalty of law, I certify that {check all boxes to indicate your agreement}:
I am the person responsible for the construction activities of this project, for satisfying the
requirements of this perrnit, 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, and
complete bases on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
I will abide by all conditions of the NCGOIWW General Permit and the approved Erosion and
Sediment Control Plan.
321 If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGQ 1QQQ0 Gene[Gene[Al P rmit 1 will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I hereby request coverage under the NSG0100DD 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.
Name of Projiect: 'A&
_legally Responsible 011111111 Panizational Entity: 14, V*k&iCAfl
Legally Responsible Person;
Title of Legally Responsible Person
Signature; 7_
`Print Name and Tale of Signed if Authorized
individual differs from Permittee:
Phone Number: ?LL4 - 5KKaRo0
Date: _ .7-6
IMPORTANT NOTE: This form must be signed by a responsible Corporate officer that owns or operates the
CanstruCtion activity, such as a president, secretary, treasurer, or vice president or a manager that is
authorized in accordance with Part I v, Secflon B item (6) of the NCGO10000 permit_
For more information on signatory requirements, see Part 1V, Section e, item (6) of the NCGO10000 permit.