NCC200248_NOI Signed Certification_20200124

Directions:
Print this form, complete, scan and upload to the electronic NOL
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 SturmwaterProgram
SlIN.Salisbury Street, 6mFloor (Office 64OK)
1612Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UATIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per N[General Statute 143-215.68 (1), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article ... shall bcguilty ofoClass 2misdemeanor which may
include ofine not toexceed ten thousand dollars /$18000/.
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 permit, and for any civil or criminal penalties incurred due to violations of this
permit.
�0 The information submitted in this NOI is, to the best 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.
! will abide byall conditions o/the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan,
if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
~`
Prevention Plan) of the I will nonetheless ensure that all conditions of
Part Uofthe permit are met mnthe project at all times.
�
1hereby request coverage under the NCGO10000 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 asanindividual permit.
Name of Project:
Legally Responsible Organizational Entity: 'T RZ PLC
Legally Responsible Person:
*Print Name and Title ofSigned ifAuthorized
�IMPORTANT NOTE: This form must be signed bynresponsible 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 6, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.