NCC201551_NOI Signed Certification_20200424

NCG01 Notice of Intent (NOO Certification Form
Directions:
i
Print this form, complete, scan and upload t� the e'ek:tronic NO
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check rrpuyrr g by check) at
1 Division of Energy, Mineral & Land Resources Stormwater Program
512 N Salisbury Street, 6' Floor (Office 640K)
I 1612 Ma: Serfsce Cente,
I
Raleigh, NC 27699 1612
i f)D NOT MAIL THIS FORS.' '
)'_ 'r'." Genera! Statute 14.3-11-) 66 ,t a:y prrsor, .vho kyo;,V • f, a-V fc;
. , r rrfrcatron in any applicc=rr, rCLo,d resort, p'on. or c
:h,s srtrtf2 orarule rn r :rr,•. rn3 thy: Artele ;r,:9 C g.:rtty G.fr, rrJ-" ,�
not to ex-eed - r t :., .onp dollops (S 1-0,;.
Gc''S-.7 r_ , i,1 - fc- I: , •:C, .. _ r fo:
,,..,reme^t5 of t 'S f cr•rit. ard'cr any Ctiti [
rtr,i-
i he information, s,:b�-•rzied it this NCI is, to the best of m} kn-: !_v; c. . k, r= '•::
_ cm. plete based on my inquiry of the person or persons who r'.ar•,age tr' sY.<<rr,
d•rectly responsible for gathering the information.
t I will abide by all conditions of the NCGO10000 General Permit and the approved fros:on art
Sediment Control Plan.
JR If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part if of the permit are met on the project at all times.
I hereby request coverage under the NCGO10000 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.
'Signature:
" Date: 4-8-2020
'Print Name and Title of Signed if Authorized
Individual Differs from Permi}ttee:
Phase iNumber
+ fWPORTAAOTNO•rE_ T h!s f Yin must be signed by a responsible corporate officer that owns or operates the
c+ons&uc6m actiift, such as a president; secretary, treasurer, or vice president, or a manoger that is
au[hor .eed in aawdbrke with Port IV, Section 8, Item (6) of the NCG010000 permit.
For rnore h7formotwn on signatory requirements, see Part IV, section 8, Item (6) of the NCGO10000 permit
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