NCC200024_NOI Signed Certification_20200219

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Print this form, complete, scan and upload tothe electronic NO|.
Then, mail the original form to the NCDEM0StormwaterProgram (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StormwoterProgram
512N.Salisbury Street, 6mFloor (Office 640K)
1612 Mail Service Center
Raleigh, NC27699'1612
W,O NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation,
mcertification in any application, record, report, plan, mother documentƒledmrequired to be maintained
under this Article ororule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include o/henot toexceed ten thousand dollars ($10,000).
Under penalty uflaw, | certify that (check all boxes toindicate your aQreememt):
[XI |amthe person responsible for the construction activities ofthis project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
OD 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.
IX | will abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
QQ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) nfthe NCGO10000 General Permit | will nonetheless ensure that all conditions of
Part Uofthe permit are met onthe project atall times.
C� | 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 ason individual permit.
Name ofProject: Albemarle Business Center
Title of Legally Rpsponsible Person: City Manager
*Signature: Dat,=./ /1(-) Zo
*Print Name and Title oiySigned if Authorized / -t
Phone Number: 704-984-91
*DMPORTANT&OTE. This form must besigned byoresponsible corporate officer that owns or operates the
construction activity, such ascpresident, secretary, treasurer, or vice president, oromanager that is
authorized inaccordance with Part IV, Section B,/tem (6) of the NCGO10000permit.
For more information on signatory requirements, see Part IV, Section B, Item (6)nfthe N[GOU00O permit.