NCC201735_NOI Signed Certification_20200429

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this farm, compute, scan and upload to the ek-ctrornc NOI.
Then, mail the original form to the NC DLMLR Stormwater Program (with $100 ehe-a if paying by check) at:
Division of Fncrgy, Mineral k I and Resourcv% Stormwater Program
512 N. Salisbury Street, V" tIvor (Otlice 640K)
1612 Mail service Center
Raleigh, NC 1t699.1612
Per NC General Statute 143-715.68 (i), any person who knowingfy makes any raise statement, reprc-sentattan,
or certification in any application, retard, report plan, or other dorumernt fired or required to be maintained
under this Article or u rule implementing Cltr'-t Article ... shall be guilty of a Class 2 misdemeanor which rrruy
include a fine not to exceed ten thousand dollars ($10,01V).
Llrttfe+r e•nalty of law, I c e•rtily that ti.Iit.-ek all boxes lu ifitll(-ite guilt .IRrcetriont)
I am Lilt• pvrson responsible for the construction actMties of this project, for satisfying the
I Uq1Jite-ruri11% of t1w, I"'I Ind, .tied for any r Iv,l it ctinlinai Im-miltim irK-acted title to vinlattnw.(it this
permit-
f fie infnrmatian %tibmitted in this NOI is, to the best of my knowledge and belivf, true, accurate, anti
ILIUMPIVte bx.ed oti my inquiry of the pei-rM nr Pet%011s who manage tfrf -.y"tern, of tlper�.o:, ,
dire-0y responsibfc for gathering the: information.
f I will ahide by all eesndittons of tht• I l i r ' �' � ii :•' .1-i,,•r„, arul the appiove d I rnsion arrei
Sediment Control Plait.
If the approved Ftosion and Sediment Control Plan is not cornpfi nt with Part II (Stnrrnw,aIe•r Pollution
Prevention Plart) ofth+' "J+ i "� �` �'' i'T • ii '• ', ', I will noncthelm% ernui r that all tondtt icim c:;
Part II cif the per rnit are met on the project at al tirnt-s_
t hereby tmltit5t tour -rage under the I,r r,�J 110J1 t•, r ,_ Pt"r tit 310 lhdt eow•rago. untfe•r
this permit will wttstitute the permit requirement~ forthe diWt iarRe(s) and is enforceable i i i the
%aloe manner A% mi irAividll.tl Perrlait
Name of Project: "AMA,"
tegalIV Responsible Drgannational EnMy: t*riat IA-.. C.Q—toving C N viLt O
Legally Responsible Person:•►t - —
T-rrfe of Legally Responsible son: fast-yIL
'Si nature: _
*Print Name and Title ❑t Signed if Aurhori*
individual Dr'fff7s Pram Permittev, � � e
Phone Number: 7y"
Oate: t r e
i�4S eQ-1
1MPORTA1Nr NOTE: This farm must be signed by a responsible corporate off ter that Owns or operates the'
construction activity, such as a president, secretary, treasurer, or trice president, or a manager that is
outhorized in accordance with Parr IV, Section 19, item (6) of the NCGOIOCw Permit,
For more information on signotory require runts, see Part IV, Section d. itern (6) of the NCGD-10000 permit.