NCC201146_NOI Signed Certification_20200320

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form., complete, scan and upload to the eIectronic NOI.
Then, maid the original farm to the NMLR Stormwater Program (with $100 check if paying by checks at:
Division at Energy,, Mineral 8e Land Resources Stormwater Program
Sly N. Salisbury Street, 61h 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)., Qny person who knowingly makes any#olse statement, representation,
or Cert►freatran in any opplrcation, record, report, plan, or other document filed or required to be maintained,
under this Article or o rude implementing phis Artr'cIe ... sho!l be guilty of cr Gloss 2 misdemeanor which may
include a dine not to exceed den thousand dollors($10,000).
Under penalty of law, I certify ecal! boxes to indicate your agreement}:
Vm the person responsible for the construction
requirements of this permit, and for any civil or criminal s of this project, fir satisfying the
permit. penajties incurred due to violations of this
The information submi0
tted in this N01 is., to the best of my knowl
complete based on my inquiry of the person or persons who man die and be��ef, true, accurate, and
directly responsible for gathering the information. age the system, or those persons
I will abide by ail conditions of the NCGO10000 General Permit and the approUed Erosion and
Sediment Control plan.
If the approved Erosion and Sediment Control Phan is not compliant with Part If (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that ail can i '
Part If of the permit are met on the project at all times. d #�Qns of
I hereby request coverage under the G010000 General Perm"t and understand that coverage under
this permit will constitute the permit requirements for the discharge(s) and is enforc
same manner, as an individual permit. e�ble �n the
Name of Project.- WlNifaU C4,eek
Legally Responsible Organizational Entity: Tiet le A h�hfef
Legally Responsible Person: t4W-6? �t�VS
Title of Legally Reg"
sible Person.- Eftl'lifati g & �'¢YnllttiH9 ¢GiRI%Jt
'Signature:
*Print Name a
Individual Dif
itle of Signed if Authorized
rs_ from Permittee:
Phony Number: 94-9•k72.0991
date:
3-13-202D
* IMPORTANT NOTE,' This form mist be signed b o responsible corporate
construction activity, such as ❑ president, secretary, treasurer, or �Q officer that owns or operates the
authorized in accordance with Part IV, Section 8, �rE� ��� o t�� NCGO1r or a manQger that �s
�0000 permit.
For more informo6on an srgnQtory requirements Item
see Part I V$ Sec tio n B Item
(6) of the NCGO1 0000 p ermit.