NCC201571_NOI Signed Certification_20200420

N0001 Not
ce
f Intent (NOI) Certification Form
Directions:
Print this form,
co
mplete, 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:
Division of E
ergy,
Mineral & Land Resources Stormwater Program
512
N. Salisbury
Street, 6'h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM
C,
R PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWE
AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6B (i), a
y 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 guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousond
dollars ($10,000).
Under 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, an
for any civil or criminal penalties incurred due to violations of this
permit.
The information submitted in &
is NOI is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of
the person or persons who manage the system, 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.
1,6 If the approved Erosion and Seciment
Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG01011000
General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on
he project at all times.
Ik 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. I...Atlrrawo FAjrms
sullflw,SIAAI P.44W ,Z.
Leg
Ily Responsible Organizational, Entit�,:
.. 4mEr, A 6xsE r .T,vC.
Leg
311y Responsible Person: , JA)4s,
it
Titl
of Legally ible Person:
mu
*Signature:
Date: 4 17 20
*Pr
nt Na and Title of Signed if Authors
ed
In
ivi ual Differs from Permittee:, V
A
Phc
ne Number. gig 917 —
62%9
k IMPORTANT
NOTE: This form mush 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
out
orized in accordance with Part 1V, Section
8, Item (6) of the NCG010000 permit.
For
nore information on signatory requirements,
see Part 1V, Section B, Item (6) of the NCG010000 permit.