NCC200186_NOI Signed Certification_20200123

NCG01 Notice of Intent (NO1) Certification Form
D ire-r-tion s:
Print th is Fa rm, cornpl etc, 5ran and u plaad to the L%Ie n is AI0I.
Therr, rrMaiJ the original form to the NC DEM L R Stormwater Progra m (with $ W check tf paying by C-twck) at:
DIVisian of E ni,-rgy, Mi neral & Lan-d Resou rres Stairmwater Program
512 Af- Salisbury Street, 6t' Flaor {Qfiice 640KI
1612 Ma W Ser icL' Center
Ra Iaigh, N C 27649-1 GJ.Z
DO NOT MA It TH 15 FO R M 0 R PAVIV ENT U NT I L YOU R APPEiCATJ ON HAS BEEN
REVI EWER A N D ACCE PTED A5 CID M P LETE
P-F-V MC �enerod StaftrtL- 143-215-&R (j)r GOY Persan who knowingly smokes any pilre statement represeneaR[ion,
or a&rtrficatiorr ;rF i7ny applrccrfjan, recoFd, reps praa, or Other dGruxrWnt filed or requvrpd to be fiMj]rrrtained
under this ArtW& or a rule lmpIementing this Artwie , . , rhdlr be gc tty of a Ga55 2 m;sdemeanar which ma[+
ilhel'Jde o fine nOt 60 exc8ed [err thnu5andr dollars
Under nal ty of law, I certify that I cheek a II boxes to indicate your agreement)
71 am the person respan!5ible for the cc3nstrLicJon activities of this project, for sati5 [n the
�Y g
r�!qui cements Of the-5 permit, a n d for arryr civil or cflmanaj p na.ltip.5 incurred due t-13 rriolatiorrs of this
permit.
The information submitted in th is NOS is, to th a best of mar knowlecige a rid bel ie r truer accu rate., and
oagn plete based an mar incluiryf of th a persorti or per5on5 vwh o m ana$e the SYstemr 10 r those persons
dirorCl�r responsible for gatMtering the inform-atian.
wiJr abide by al I Bond it[4Dns of tl�L% N0 010000 General Permit and the approY-2d Frnsion artid
5ed[m ent Control PI ar7,
1If the approved E rasion a nd Sediment Control Plan is not card p1 is nt witFt -Part it (5tnrmwater Po1luti4?rti
Prevention Plan) of the KCGQ LQW0 neraJ PermiL I will noncheless il-rnsure that all eortidi tinnS of
Part II of the permit are met on the project at all tiro es.
F kvi ifbyr r cquest coverage u n d P. r the KCG01 Ge;neraJ Perrnlz and u ndurstand that wverare under
th is permit wi[I con sti to to tihe permit r-equiremer,ts fl3r the d isch argc(s) a n d is enforceabia [n the
sa m e rraa n ner as an individual perrnit.
Narne of Prajeel_ T� �� �
lega Icy Responsihl ❑ rgafli ate rti�l IErrtity, _ r ,
Li�gaily Responsibl a Person$ J L
Ti He of Legally mes i b1e PIWOn = �
* Rrint Na m p a n Title 0f 5+gned jf AvdW iMe
in diyl[dual or#fers from permirtee.
_ Phcpne Number, 91.0, -Z{ s� r gv q eI
* ltlVVJ?TAAFT NOTLw: 1]`tr's form Must be signed by a raespo6sibre 47o poste off Cer that awns -Or 40per-g[e5 the
cm-itructiorp uct ry t)r, Arch as a p-srdenk secretary, [reusurer, or vice presidents -GT o rnai lager fhot is
authorized if? accordance with Pan IV, section 8, otem (6) of the, N lowopermit,
r-GV MOfe irrfafmptr On Sigrr47tWy erCqUjreML7n[5, Flee art IV, SWiOrt 8, Item (G) of the NEU01fflM permit.