NCC201179_NOI Signed Certification_20200420

NCG01 Noticl of Int nt (NQI) Ce ificat:ion Form
Directions:
Print this for complete scan and upload tot a electronic NOL
Then, mail the original form to the C DEMLR tormwater Program( ith $100 check if paying by check) at:
Division of Ene gy, Minera & Land Resources St rmwater Program
512 Salisbur Street, fi`h Floor (Offi' e 50K)
1612 Mail Service Center
Rale' h, NC 27699-1612
DO NOT MAIL THIS FOR OR PA MENT UNTIL YO4 RI AP'
ICATION HAS BEEN
REVIE ED AN ACCEPTED AS C MPLETE
Per NC General Statute 14.3-215.6B (1 1, any pers n who knowingly ma s qny false statement, representation,
or certification in any application, re ord, report plan, or other dorri nt filed or required to be maintained
under this Article or a rule implemen ing this Ar 'cle ... shall be guilty f Class 2 misdemeanor which may
include a fine not to exceed ten thou and Jolla ($10,000).
Under penalty of law, I certify that (c ieck all bo es to indicate your agreement):
2 1 am the person responsibl for the co struction activities of thi� project, for satisfying the
requirements of this permi , and for a y civil or criminal pert Ities incurred due to violations of this
permit.
9 The information submitted in this N01 is, to the best of my �i iov ledge and bellief, true, accurate, and
complete based on my inqi iry of the erson or persons who manage the system, or those persons
directly responsible for gat iering the i formation.
9 I will abide by all condition of the NC 010000 General Per it and the approved Erosion and
Sediment Control Plan.
9 If the approved Erosion an Sediment Control Plan is not co plant with Part III (Stormwater Pollution
Prevention Plan) of the NC 010000 G neral Permit I will n6eteiess ensure�that all conditions of
Part it of the permit are mE t on the pf ject at all times. l
GIa' 1 hereby request coverage nder the CG010000 General Prmit and understand that coverage under
this permit will constitute I he permit i equirements for the iscf arge(s) and is enforceable in the
same manner as an individ al permit.
Name of Project: 125 61tickli v'
Legally Responsible Organizational ntity: r ,
I
Legally Responsible Person: CL k-Cd W\km
Title of Legally Resp nsib Person: M
*Signature: I Date: i V 1 2 o
*Print Name and Title of Signed if Authorized }}
Individual Differsfrom Permittee: �O�1r1'S�V l _avvifM
Phone Number:
* IMPORTANT NOTE: This form must be signed
construction activity, such as a president, secs
authorized in accordance with Part IV, Section
Fnr mnro infnrmntinn nn cinnntnry rani
a responsible corporate officer that owns or operates the
ry, treasurer, or vice president or a manager that is
Item (6) of the NCGO10 00 permit.
cap Pnrt IV Cprtinn R Itom 161 of the N(Yr)7nnnf) nermit