NCC201559_NOI Signed Certification_20200424

NCG01 Notice of Intent (N0I) Certification Form
�Directions: - _I
Print this form, complete, scan and upload to the electrunic NO!
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check �`; ayi.�_q by check; at
Division of Energy, Mineral & Land Resources Stormwater Program i
512 N Salisbury Street, 6" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAILTNIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS E�FFt
REVIEWED AND ACCEPTED AS COMPLETE _ ..
Per NC General Statute 143-215.68 (1), any person who knowingly makes ony fulse stolemer' , representabor•
nr certification in any application, record, report, plan, or other document filed or regwred tr. be mornto.ned
b nder this Article or a rule implementing this Article ... shall be guilty of o Clnis 1 r.Trsdenrecnnr which rr 'Jy'
,ti "0de a fine not to exceed ten thousand dollars ($10,000).
r penalty of law, I certify that (check a![ boxes to ird Cate your .3 -remert)
Jr. 1 am the person responsible for the construction of t'— r ')J-t 'o:
requirements of this permit, and for any c,ri[ or cnmr,,.+, pen
permit
The information submitted in this N01 is, to the best of
complete based on my inquiry of the perso-i or persons titi - o
directly responsible for gathering the informat^on
L� I will abide by all conditions of the NCGO10000—Genera' 0-1, and t•.
Sediment Control Plan.
J!3 If the approved Erosion and Sediment Control Plan is not compliant with !' ! ; t r c is
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ens_ : ,hat a:` c: ;t : o'
Part 11 of the permit are met on the project at all times
I hereby request coverage under the NC6010000 General Per^i t and understand that core--,g r
this permit will constitute the permit requirements for the discharge(s) and is enforceable ir. the
same manner as an individual permit.
ke !�
•� Lure:-- Date: 4-8-2020
*print Name and Title of Signed if Authorized
�irdirWua!!>tfjers from Permittee:--
Ap!pR ANENOTE. This form must be signed by a responsible corporate officer that owns or operates the
cowrix norf ortiWy, such as a president; secretary, treasurer, or vice president, or a manager that is
,vitjaarkedie accordance with part IV, Section 8, Item (6) of the NCGO10000 permit.
For morn Jn/orrnacloe on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.
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