NCC201666_NOI Signed Certification_20200424

NCG01 Notice of Intent (NOI) Certification Form
Direirtions:
Pant this form, romplele, scan and uploarl to ttte electronic NOI.
Then, mad the origir►ai form to 1he NC ❑IMLR Stormweter Program (with $100 r heck of paying by rhecki at:
Division of fntrgy, Mineral a Land Resources 5tormwaler Program
512 M. Salisbury Street, 6"' floor (Office 6WK)
1612 Mail 5err4m Center
Raleigh, NC 27699-1612
DO NOT MAiL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Pirr NC Genera! Stotute 143-215.68 fil, any person who knowingly makes ony false statement, representation,
or cert'if+carion rn any application, record, report, plan, or other document filed or required to be mofntatned
under this Arrick or a rule rmpiernenting this Artic0e ... shall be guilty of a Class Z misdemeanor which may
inchide a fine not to exceed ten thousand dollars ($IO,OOO).
Under penalty of faw, 1 certify that {check all boxes to indicate your agreement)!
`?r 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.
d The information submitted in this NCIi 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.
1 will abide by all conditions of the NCG4QQ00 General Permit and the approved Erosion and
Sediment Control Plan.
0"" if the approved Erosion and Sediment Control Plan is not compliant with Part 11 JStormwater Pollution
Prevention Plan) of the NCG010000 General Permitf will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
Erl�I hereby request coverage under the NCGO1 QM Q eneraI 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 P
1 M G c --
r -
L ally Responsible 0 anizational Ent
Legally Responsible Person;
Title of Legally Responsible Person: t airzL+t
'Si nature: Date
'Print Name and Title of Sign Authorized
individual Differs Aom Permittee:
Phone Number
aU [,
IMPORTANT A1110TlE: This farm 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 iV, Section 8, item (6) of the NCG010000 permit.
Far more information on signatory requirements, see Port iV, Section 8, Item (6) of the NCG010000 permit.