NCC200111_NOI Signed Certification_20200114

NCGO1 Notice of Intent (NOI) Certification Farm
Directions:
Print this form, complete, scan and upload to the electronic NO1.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representation,
or 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 Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of lavv, I cei-rify'that ;checl: all bo,(es to indicate your agreement):
'R I am the person responsible for the construction activities of this project, for satisfying the
requirements of this per,nit, and for any civil or criminal penalties incurred due to violations of this
\— gerrni't.
'C I The information submitted in this N01 is, tothe best of my knowledge and belief, true, accurate, and
corns lete based 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 NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
1' tthe approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the It'CG0100,00 General Permit, I will nonetheless ensure that all conditions of
Part 11 of 'the permit are met on the project at all times.
I hereby reiauest coverage under the NCG010000 General Permit and understand -that coverage under
this tiermit will coiistltu,.- the I?eriillt i'el7lllrenIentS'iorthe dischargers) and is enfGrceable in the
same marine! as an individual permit.
Name of Project:L���
Legally Responsible Organizational Entity:
* Legally Responsible Person:
Title of Legally Responsible Person:
Signature:
Date: v. '�- L - � 0 .2 v
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.