NCC201402_NOI Signed Certification_20200409

NCGO1 Notice of Intent (NOI) Certification Form
Directions;
Print this form, complete, scan and upload to the electronlc N01.
Then, mail the original form to t1he f#C DE#ALK Stormrrater Pm8r8m (with 5100 check if paying by Check) at:
oms,on of EneW, ~81 & Land Resources Slormwater Program
512 N. Salisburt► Street, ti"'` f=loor Joftite 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED A
Per NC Gents! Statute I�3 115.681�1, any person who knowingly makes any false statement, representation,
or certification in any application, a
on, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementingthousand donors' le ... shall be guilty of a Class 2 misdemeanor whit may
include o fine not to exceed ten
Under penalty of taw, I certify that (check all boxes to indicate your agreement): in the
I am the person responsible for the construction activities of this project, for satisfying
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
[ The information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, an
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
010000 General Permit and the approved Erosion and
1 will abide by all conditions of the NCG
Sediment Control Plan.
[� if the approved Erosion and Sediment Control Plan is not compliant with Part Il (Stormwater Pollution
Prevention Plan) of the NCG010000 General
l Permit, I
times. ill nonetheless ensure that all conditions of
Part 11 of the permit are met on the project
p� 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:
Legally Responsible Organizational Entity: LL'
Legally Responsible Person: �—
Title of legally Responsible Person: 'l t r1
Date: (J O
*Print Name Name and Title of Sik4cl if Authorized
Individual Differs from Permittee:
Phone Number:
* 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.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.