NCC201464_NOI Signed Certification_20200413

NCG01 Notice of Intent (NOi) 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 ( wi
Division of Ener (With $100 check if paying by check) at:
gy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 616 Floor (Office 64UK)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
Per NC General Statute 143-215.6B (i), an
or certification in any application, record, report Plan, Y Person o knowingly yfolsestatement, representation
other document f led or required to be
,
under this Article or p rule implementing this Article. ,shall be guilty of a Class 2 misdemeanor which mo maintained
►nclude a fine not to exceed ten thousand dollars ($10,000J, y
Under penalty 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.
!a The information submitted in this NQI is, to the best of my knowledge and belief, true accurate,
complete based on my inquiry of the person or persons who manage the system, or those pe so snd
erectly responsible for gathering the information.
I will abide by all conditions of the 11CG010000 General Permit and the approved Erosion and
Sediment Control Plan.
I� If the approved Erosion and Sediment Control Plan is not compliant with Part it (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ensure that all conditions of
ZI
art II of the permit are met on the project at all times.
hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharges) and is enforceable in the
same manner as an individual permit.
Name of Project; rb —LoisiIg5 1 t tt1 T
Q
Legally Responsible Organizational Entity: IA% 0_ �Uome5, `...�
ally Responsible Person:
Title of Legally Responsible Person:'PS on 3iyudibr-) N rd I (\ 0-6 iz-
*Signature: Date: < a 00?0
*Print Name and Title of Syned if Authorized
Individual Differs from Permittee:
Phone Number: 9/0 - q 15 — 1100 V
* 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 NCGO10000 permit.