NCC200974_NOI Signed Certification_20200313

NCGO1 Notice of Intent (N01) Certification Form
Print this form, complete, scan and upload to the electronic NOL
Then, mail the ornal form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6 th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO 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,
or certification in any application, record, report, plan, or other documentfiled 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 a fine not to exceed ten thousand dollars ($10, 000).
Under penalty of law, I certify that (check all boxes to indicate your agreement):
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Sfor mwater 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: Yakov Meyko
RM 0 RJ VETO=
Title- of Legally Responsible Perso
*Signature:
*Print Name and Title of Si
Individual Differs from Permittee:
Phone Number: 9085007923
Yakov Meyko
Yakov Meyko
owner
Date: C 3
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 NCGO10000 permit.
PIMP=