NCC200230_NOI Signed Certification_20200128

NCGO1 Notice ofIntent (NOU) Certification Form
Print this form, complete, scan and upload tothe electronic NOi
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources 6tornxmaterProgram
S1ZN.Salisbury Street, 6mFloor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per N[General Statute 243-215.68(i),any person who knowingly makes any false statement,
o/ certification in any application, record, report, plan, mother documentfiledor required to be maintained
under this Article o/orule implementing this Article ... shall heguilty ofoClass 2misdemeanor which may
include offnenot toexceed ten thousand dollars ($2D,00D).
Under penalty uflaw, | certify that (check all boxes toindicate your :
R"' 1amthe person responsible for the construction activities oJthis project, for satisfyingthe
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
"='" The information submitted inthis NQ|is, tothe best ofmyknowledge 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.
ey ! will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
u^~° if the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit, ( will nonetheless ensure that all conditions of
Part 1/ofthe permit are met onthe project atall times.
Q�^ | hereby 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: S&J
Legally Responsible Organizational Entity: '
Title ofLegally Resm6ndblePerson: L-A1j%*5
*Signature: Date:
*Print Name And Title of Signed if Authorized
Individual Differs from Permittee:
IMPORTANT NOTE: This form must besigned byoresponsible corporate officer that owns or operates the
construction activity, such osopresident, secretary, treasurer, orvice president, nromanager that is
authorized /naccordance with Part IV, Section fLItem (6)qfthe N(G01UU0Upermit.
For more information on signatory requirements, see Part IV, Section 4Item (6) of the NCGO10000 permit.