NCC200167_NOI Signed Certification_20200115

NCGO1 Notice of Intent (N01) Certification Form
Directions,9
Print this form, complete, scan and upload to the electronic NOI.
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 Stormwater Program
S12 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (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 law, I certify that (check all boxes to indicate your agreement):
Z l am the person responsible fol the construction activities of this project, for satisfying the
requirements of this permit, any, for any civil or criminal penalties incurred due to violations of this
permit,
The information submitted in this N01 is, to the hest of my 'Knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
C ' I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erasion and Sediment Control Plan is not compliant with Part it (Stormwater Pollution
Prevention Plan) of the CG01 o 00 G enera=_'Permit, I will nonetheless ensure that all conditions of
Part II of "the permit are reset on the project at all tit -ties.
I hereby request coverage under the NCG010000 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 Project:
Legally Responsible Organizational Entity:
Legally Responsible Person: `�p{A�,.�.�,�
Title of Legally Responsible Person: A&
EyhaQ,r(
*Signature:
*Print NaiTf z id Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: A1q*11D119���'
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* 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 B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.