NCC201026_NOI Signed Certification_20200316

Print this form, complete, scan and upload to the electronic NOL'
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 StormwatorProgram
- -512N.Salisbury Street, GmFloor 0MiceS40K
1612Mail Service Center
Raleigh NC27§99-1O1I
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOU R APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (1), any person who knowingly makes anyfalse statement, representation,
mcertification inany application, record, report, plan, or other documentfiledor required to be maintained
under this Article ororule implementing this Article ... shall beguilty 4fa Class 2misdemeanor which may
include offnenot toexceed ten thousand dollars ($1(l000).
Under enalty of law, I certify that (check all boxes to indicate Your agreement):
1 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.
O� 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.
-_�
D� | will abide byall conditiomsofthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
~-� if the approved Erosion and Sediment Control Plan is not compliant with Part 1|(Stmrmwate,Pollution
Prevention Plan) ofthe NCGO10000 General Permit \ will nonetheless ensure that all conditions of
Part ||ofthe permit are met mnthe project atall times.
) 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 asanindividual permit,
*Print Name and Th9ufSigned if Authorized
Individual Differs from Pennittee
Phone
~IMPORTANT NOTE: 7his/bnnmust besigned bynresponsible 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,/tem (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section S, Item (6) of the NCGO10000 permit.