NCC201657_NOI Signed Certification_20200424

NCGO1 Notice of Intent (N01) Certification Form
Directions:
Print this form, complete, scan and upWd to the electronic NOI.
Then, mail the original form to the NC DEMI_R Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral b Land Resources Stormwater Program
S12 N. Salisbury Street, 6`" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NO"I' MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.58 (1), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (cheek all boxes to indicate your agreement):
I 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.
N( 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.
l/ I will abide by all conditions of the 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 II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
L� I hereby request coverage under the NCG010000 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.
Name of Project' CaXQpinej Phalle, ,ZrT o4 0+� 3
Legally Responsible Organizational Entity: H f A Conns�rlA�,
Legally Responsible Person: $rtOlrl Wal1CP,�
Title of Legally Responsible Person:
�
*Sienatul'e:
`Print Name and Title of Signed if Authorized
Individual Differs from Perm ittee;
Phone Number: 110 _ Y8j6` 664
Date:
1AVOi,'.EANT NOTE. This form must be signed by o responsible corporate officer that owns or Operates the
construction activity, such as a 13residenz, secretary, treasurer, or vice president; or a lrranager that is
authorized in, accordance with Part W, Section B, item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part A/, Section B, item (6) of the NCG010000 permit.