NCC201350_NOI Signed Certification_20200403

NCG01 Notice of latent (N01) Certification Form
Directions:
Pr€nt this form, complete, scan a nd upload to the electronic N01,
Then, mail the original form to the NC DENILR Stormwater Program (with $100 check ifpoying by check) at:
Division of Energy, Mineral & Land Resources Storrnwater Program
512 N. Salisbury Street, din Floor (Office 640K)
1612 Mai Service Center
Ralelgh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC Gen eral -5to Eu te 143-215.68 (i), orgy person who knowingly makes any fa)se statement, representation,
or certffrcariorr In any oppiication, record, report, pion, or other document flied or required to be maintoioed
under- this Article or a rule implementing this Article - , . shall be gui)ty of a Gass 2 misdemeanor which may
include a fine nor to exceed tern thousond dollars � 10, 0)-
under penalty of law, I certify that (check al I boxes to indicate your agreernent):
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,
L The information submitted in this NOI is, to the best of my knowledge aM belief, true, accurate, and
complete based on my inquiry of the person or per5on5 who manage the systern, or those persons
directly responsible for gathering the information.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan,
If the approved Frosion and 5edirni�nt Control Plan is not compl iant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at al I tirnes.
I hereby request coverage under the NCG010000 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; PN Q Line 243 Retrofit Launcher _
Legally Responsible Organizational Entity: �e +IAn Gt% � �Vw „0-^
Legally Responsible person;
Title of Legally Responsible Iverson- v\i p C.�—
*Signature: } Efate, Oq r a 1
* Print Name and Title of Signed if Authorized
individualD+ffers from Permittee,
Phone Number- 74) 13 ll �
* IMPORTANT NOTE: This fora must be signed by a responsible corporate officer that owns Or operates the
constructiorn octivity, such as a president secretary, treasurer, or vice president, or a manager that is
authorized in occordanace with Part IV, Section 8, item lf6] of the NCG010008 permit.
For more information on signatory requirements, see Part IV, Section B, ftern (6) of the NC'GO1 0000permit.