NCC200589_NOI Signed Certification_20200217

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Print this form, complete, scan and upload to the electronic N0.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources 5turmwate/Program
512N. Salisbury Street, 6`^Floor (Office 64UK)
1612Mail Service Center
Raleigh, N[27S99'161Z
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PerN[Genero/Stotute243-2D5.6B(i),onypeuunwhoknowinylymokesony/obestot«mont/epresen/obon
orcertification /nany application, record, report, plan, orother documen(filedorrequired tobemaintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include ofine not to exceed ten thousand dollars ($I0,000.
Under eno|tyof |avv, | cerfih/that (check aU boxesto mdicate you/ a�reemen,)�
*� | an: Uhe peoon r�spons/b|e forthe cons1rucdun acnvit/e�of �hs p/o]�cr. �orsans�ym0 ��e
,equi/emen�o/this permi�'an(J|u,anyCivil oroimina|�ena|ne��ncunedduwoovm|ation�ofmo
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mformat/on submitted inthi^ NU \hebextufn�yko"w|wd�eand beUe� �rue. accura�c. �nu
comp�ete based on mymgu.ryo[d`e person orpecon�vvho nnanuQe the y/�em' o/thou persons
/ direct|yesAonsib|e hor�ath�rin�the m|ormo1ion
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Legally Responsible Organizational Entity: C \
Legally Responsible Person:
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Title ofLega|k/Responsible Person: '`)ri'Ic— . '\/^ ^~'f `
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*PrintNameondTideofSignedJAu/hu/bed
Individual Differs from Permittee:
IMPORTANT NOTE: Thisform, must be signed byoresponsible corporate officer that owns moperates 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 NCG010000 permit.
For more information on signatory requirements, see Port IV, Section B, Item (6) of the NCG010000 permit.