NCC201755_NOI Signed Certification_20200501

NCGO1 Notice of Intent (N01) Cert'bfi ication Form
Directions,.
Print this form, complete, span and upload to the electronic N01.
Then, mai{the original form to the NC DEMLR Sto rmwate r Program with $100 check if paying by check] at:
Division of Energy, Mineral &Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 64OK)
1612 Mail Service Center
Raleigh, NC 27699-1512
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED -AND ACCEPTED AS COMPLETE
Per NC General5tcrtute 143-215.6B (i),. any person who knowingly makes any false statement, representation,
or certification in any application, record, repot, plan, or other documentfiled or required to be maintained
under this Article or a cute implementing this Article ... shalt be guilty of a Class 2 misdemeanor which may
include ❑ fine not to exceed ten thousand dollars ($10, 000).
Under penalty of law, I certify that (check all faxes to indicate your agreement:
�7 I am the person responsible fvr 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 N01 is, to the best of my knowledge and belief, true, accurate, and
complete based an my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information.
F7( I will abide by all conditions of the NC.GOI0000 General Permit and the approved Erosion and
Sediment Control Plan.
Y If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plank of the NCGa10OO4 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
i hereby request coverage under the NCG01O000 General Permit and understand that coverage under
this permit will constitute the permit requ +cements for the discharges) and is enforceable in the
same manner as an individual hermit.
Name of Project:
Legally Responsible organizational Entity: �i'l vtVL.� �j or� Y ity: S+rvL � _ _
Legally Responsible Person:
Title of Legally Responsible P
Signature:
son
V,
lil l�
rr�_ e.. i,,-k000'
*Print Name atfd Title of Signe&if Authorized
Individual Differstram Permittee:
Phone Number: � • ��0
Date: zy
* IMPORTANT IIIQTF: 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 IV, Sectrorr B, item (6) of the 111CG01 04O0 permit.
For more information on signatory requirements, see Part IV, Section 6, Item (6) of the NCG01D000 permit,