NCC200869_NOI Signed Certification_20200311

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DFMI.R Stormwater Program (with $100 check if payinq by ctwck) at:
Division of Energy, Mineral & Land Resources Stormwater Program
S12 N. Salisbury Street, 151" Floor (Office 640K)
161-2 Mail Service Center
Raleigh, NC 27699-1612
DD NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS SEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-2L5_68 N, any person who knowingly makes any false sfatemeni, 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 thrs 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):
�f am the person rrrsponsihie 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.
IK The information submitted in this 1`401 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.
C1l/ I will abide by all conditions of the NCGO10000 General Permit and the approved Erasion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan] of the NC'GO10000 GenuraI Permit, I will nonetheless ensure that all Conditions of
Part II of the permit are met on the project at all times_
6"� I hereby request coverage under the NCG010000 Gerwral Permit and understand that coverage under
this permit will Constitute the permit requirements for the discharges) and is enforceable in the
same manner as an individual permit.
Name of Proiect-
Legally Responsible Organisational Entity
Legally Responsible Person:hau �T
f !
Title of Legally esponsible Person: e
`Signature: Date:
*Print Name a Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number J g 9
IMPORTANT NOTE. This form must be signed by a responsible corporote 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 8, item (6) of the NCGOI0000 permit,
for mare information on signatory requirPrreents, see Fort IV, Section B, item (6) of the NCG0100oo permit~