NCC200349_NOI Signed Certification_20200130

NCGO1 Notice of Intent (NOi) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the ariginaI form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Q0 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
€ EVIEWED AND ACCEPTED] AS COMPLETE
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,OOO).
Under penalty of law, I certify that (check all boxes to indicate your agreement);
Ed' I am the person responsible for the construction activities of this project, for satisfying the
requirements ofthis permit, and for any civil orcriminaI penalties incurred due to violations o€this
f permit.
C� The information submitted in this NO1 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.
l I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If tine approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
1! Part II of the permit are met on the project at all times.
1 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 ,runner as an indivi.dual permit.
Name of Proiect:
Legally Responsible Organizational En
Legally Responsible Person: LAW
Title of Leealiv-Pw6ioonsible Person:
*Signature:
Cate: 112.illow
*Print Name and Title of Signed ifAuthoriMd
Individual Differs from Permittee:
_ Phone Number: g19)r,i42_ 4 4 -
* 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 1V, Section 6 Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part 1V, Section e, Item (6) of the NCG010000 permit.