NCC200861_NOI Signed Certification_20200304

NCG01 Notice of Intent fNUI) %.C<<rrr..a
Directions:
Print this form, eonVlete• scan and upload to the electronic Not.
Then, mail the original form to the NC DEMIR Stormwater Program (with sloo check if paying by check) at:
Division of Energy, Mineral 8& Land Resources Stormwater Program
512 N. Salisbury 51reet, 61"' Floor (office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM GRAYOUR
COMPLETE APPLICATION HAS BEEN
REVIEWED ND ACCEPTED AS
Per tvC General Statute 143-215.68 N, 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 o fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
B The information submitted in this th0l person or persons who is, to the best of my knowledge dbelief,
true, d
managethesystem,or those persons
complete based on my inquiry of p
directly responsible for gathering the information.
1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
($ I 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 as an individual permit.
Name of Project.
llv Responsible Organizational Entity
Ily Responsible Person: X�
Title of Legally Res
oonsible Person: -VH
*Signature:
*Print Name and Title of ned if Authorized
Individual Differs from Permittee:
Phone Number:
- 05, 741 N
1UcN
Date: 3,036)9 a ID
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 IV, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.