NCC201062_NOI Signed Certification_20200330

NCGO1 Notice of Intent (N00 Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Divlsion of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 611 Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Per NC General Statute I43-2I5.6B (I), arty person who knowingly makes any false statement, 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 this Article ... shall be gufity of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
�lnder 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
` permit.
\ LA The information submitted in this N01 is, to the best of my knowledge and bellef, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible far gathering the information.
�j I will abide by all conditions of the Nf-6010000 6viit- raI Pei tniI and the approved Erosion 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 r,010u00 (wi„•r01 114,�rmt, 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 NU;01([H]0 Ge.+ier.il Perfmi and understand that coverage under
this permit will constitute the permit requirements far the discharges) and is enforceable in the
same manner as an individual permit. 1
Name of Project: Jr I � T r
legally Res onslble Organizational Entity: •S
Legally Res onslble Person: ,44,
'Print Name and
Individual Differ
Phone Number: e2l�a " 15a / 'c7 -
` 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 8, Item (6) of the NCG0I0000 permit,
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCG010000 permit.