NCC201664_NOI Signed Certification_20200424

NCGO1 Notice of Intent (NQI) Certification Form
Directions
Print this Form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with S100 check if paying by check) at:
Division of Energy, Mineral B Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699.1612
D❑ NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.68 fi f any person who knowingly makes any false statement, representation,
or rertcatian in any application, record, report, plan, or other document filed or required to be maintained
Under this Article or a rule Implementing this Article .meanor which may
..shall be guilty of a Class 2 m►sde
include a fine not to exceed ten thousand dollars �$10,000),
Under penalty of law, I certify that (check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project, for satis in the
requirements of this permit, and for any civil or criminal penalties incurred due is violations of this
permit.
The information submitted in this NQl 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.
ir✓' I will abide by all conditions of the NCG01 "General Permit and the approved Erosion and
Sediment Control Plan.
27' If the approved Erosion and Sediment Control Plan is not compliant with Pan II (Stormwater Pollution
Prevention Plan) of the NCGOlUppp General Permit I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
iU' I hereby request coverage under the NCGOJQW General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharges) and is enforceable in the
same manner as an individual permit.
Name of Project:
Legally Responsible organizational Entity: �1{+
Legally Responsible Person:
i
Title of Legally Responsible Person: 1
`Print Name and Title
Individual Differs fro,
ed if Authorized
Permittee:
(Airvx f-n r
Date: y Iti 9()9U
Phone Number: qlo -
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president or a manager that is
authorized in accordance with Part 1V, Section B, Item (6) of the NCG0I0000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCG010000 permit,