NCC201578_NOI Signed Certification_20200421

NCGO1 Notice of intent (N01) Certification Form
Directions:
Print this fofm, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC OFMI R Storrrrwm t Pracf im (with $alt] check if paying by check) at;
flivkion of Enprgyr, Nlinpral & land & snurces Stormwatm Progfam
512. N. Salisbury Street, E" Floor (Office &4 OK)
1612 Mail Scrvice Canter
Raleigh, NC 77699-11b12
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPUCATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGencrof Statute 143-2I5.68 (rj any person: who knowingly makes any false smternent reprMntatran,
or certification in any app4cabon, record report pion, or other document filed or required to be nwintained
under this Arvde or a rule implementing this Article .. , shall be gailty of a CX w 2 misdemeanor which may
indude o fine nor to exceed ten thousand do0crs (510 000).
under nalty of law. I certify that (chuck all boxes to indicate your agreement);in 2Q I .n the person responsible for the construction activities of this project, for xtitl wing the
r 1 requirements of this permit, and for dfry civil or criminal penalties incurred due to violations of this
permit.
The information submitted in this NO is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manape the system, or arose persons
irectfy responsible for gathering the inl tuna; ion.
XI will abide by all Lor,dittOns Of the NCG(II G nerd( Permit and the approvtMd Erosion and
dimettt Control Plan
# the approved f roman and Sediment Carrtroi Plan is not rxsmpliant with Part II (5torfnwater Poi:utlon
Pr;n4prit�on Plan) of the KUI ,IIlQiXK) CrQ �c r�l I'C'rr.i twill noncthelesx ensure [has ail ennditions of
art II of the permit are met on the project at all times.
hereby request caverage under the %X c,C-IN%() r:i•<rral Prrmrt and understand that coverage +ender
this permit w;l; constitute tht permit requirements Fol the discharge(s) and is enforceab&e in the
same mannef as an individual permit.
Name of Project. �J�. �V.*--
LepResponsible Organitatidnal Entity. D(,.+.,il 1 v L
Lerg�liy Responsible Person:. L1
Title of Lepalponsibie Person: + 1� -� ■r
_ Da?e_ �-lam-Z•
'Print and 7Yde of signed rf Authorized
tndevsdual Differs from Permirtee.
Phony Number: ?/.I em 12 2
1UPORTANT NOTE: This form must be signed by a respon%ihlr re)rparrrtr offir.ef that owns of operates the
construction activity; wch uti rr rrepsurer, or yke president, or a monciaer that k
authurired in ocrordanre wrrh Parr lV Section B, frern (E) of the NCG010000 SIC mit.
For more information on signutury rcqurremr:nb, see Port IV, Section 8 Item (61 of the NCG010000 permit.