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HomeMy WebLinkAboutNCC200832_NOI Signed Certification_20200305NCGO1 Notice of Intent (N0I) Certification Form Directions: Print this form, complete, scan and upload to the electronic NQI. 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 5tormwater Program 512 N. Salisbury Street, 6th Floor (Office 640K) 1612 Mail Service Center Raleigh, NC 27699-1612 D❑ NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE Per NC General Statute 143-215.6E (ij, any person who knowingly makes any false statement representation, or cert►fication in any application, record, report, plan, or other document filed or required to be main toined 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 ($10,000). 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 perm it. IR The information submitted in this NDi 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. I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and Sediment Control Plan. —lx If the 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 Part II of the permit are met on the project at all times. ® I hereby request coverage under the NCG010000 General Permit and understand that coverage under this permit will constitute the permit requirements far the discharge(s) and is enforceable in the same manner as an individual permit. Name of Project: Town of Nags Head W. Side Multi -Use Path PH 8C Legally Responsible ❑rganixationaI Entity: Town of Naas Head Legally Responsible Person: Cliff Og burn Title of Legally Responsible Person: Town Manager *Signature: *Print Name and Title of Signed iAuthorized Individual Differs from Permittee: Phone Number: 252.449.2010 Date: Feb.28 * 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 IVC60I0000 permit. For more information on signatory requirements, see Port IV, Section B, Item (6) of the NCG010000 permit.