NCC201727_NOI Signed Certification_20200430

Directions:
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 of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6"' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
REVIEWED k ACCEPTED AS COMPLETE
Per NC General Statute 143-115.6811 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 o fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that (check all boxes to indicate your agreement)
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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.
'Y 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 by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
1 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 as an individual permit.
Name of Project: j!�: C)c ✓I i /
Legally Responsible Person: PP ,�
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*Print Name and Title of Signed if.
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operattes the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that
authorized in accordance with Part IV, Section 8, Item (6) of the N00010000 permit.
For more information an signatory requirements, see Part IV, Section 8, Item (6) of the NCG010000 permit

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Construction Stormwater: Notice of Intent (NOI)
National Pollutant Discharge Elimination System (NPDES) apphcatron for coverage under North Carolina's
General Permit NCG0100M STORMWATER DISCHARGES associated with constrvction activities (or
NCG250000)
A, Project Information l B. Permittee information I C Site Contact information FD, EaSC Plan
E. Certification
Forth Carolinas General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false statement, representation, or certfflication in any application, record, report, plan, or other
document filed or required to be maintained under Ibis Article or a rule implementing this Article: or who knowingly makes a false statement of
a material fact in a rulemaking proceeding or conlested case under this Article: or who falsifies, tampers with, or knowingly renders inaccurate
any recording or monitoring device or method required to be operated or maintained under this Article or rules of the Commission
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:
✓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.
The information submitted in this NQI 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 by all conditions of the NCGO10000 General Permit and the
approved Erosion and Sediment Control Plan.
* ✓If the Erosion and Sediment Control Plan approved by the delegated program
is not compliant with Part li (Stormwater Pollution Prevention Plan) of the
NCGO1000D General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
✓1 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 as
an individual permit.
Specify if you are: * ✓The Responsible Person named on this Notice of Intent
Authorized Responsible Person'
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Important: The person who electronically signs this Certification above must be the same person who signs the NOI
Certification Form. if that person is signing on behalf of the Permittee. that individual must be an authorized
responsible person within the same organization as the Permittee. '"An authorized individual is a responsible corporate
officer who 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 B, Item (6) of the NCG010000 General Permit. For
more information on signatory requirements, see Part IV, Section B, Item (6) of that permit.
Signature* �� ��5igry�v��/'
Type dame y
Title
OrganizationLegally Responsible Entity
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Date �' Date captured on f p submission
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