NCC201654_NOI Signed Certification_20200424

Print this form, complete, 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 ofEnergy, Mineral & Land Resources Stormxwate,Program
S12N.Salisbury Street, 6mFloor (Office 640K
1612 Mail Service Center
Raleigh, NC 27699-1612
-010 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute2���6B (i), any person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled or required tubemaintained
under this Article ororule implementing this Article ... shall beguilty ofoClass Jmisdemeanor which may
include ofine not &oexceed ten thousand dollars /$1(l00Ly.
Und penalty nflaw, | certify that (check all boxes toindicate your agreement):
[� 1 am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
The information submitted in this 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 byall conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
L� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe NCG010000 General Permit | will nonetheless ensure that all conditions nt
Part ||ofthe permit are met onthe project atall times.
| 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 asanindividual permit.
Name of Project: T h,&
Legally Responsible Organizational Entity: R or_� e )4* "V% 4:0 o-'ce->
Legally Responsible Person: Z- '� ~e;4—
-Title of Legally Responsible Person: Me, t
-*Signature: Date:
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee:
*IMPORTANT NOTE. Thisform must be signed byoresponsible corporate officer that owns moperates the
construction activit)4 such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information onsignatory requirements, see Part IV, Section B,/tem (6) of the NCGO10000 permit.