NCC201759_NOI Signed Certification_20200501

NCGO1 Notice of Intent (N I) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, mail the original form to the NC €BEM LR Stormwater Program (with SIDO check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 5" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC Generol Statute 143-215-68 (i), Orly person who knowingly makes anyfalse statement, representorlon,
or cert0fication ir? a0y application, record, report, plan, ar other docurnent filed or required to be maintained
under this Article or a rule trrmplemendog this Article .. , shall be guilty of a Class 2 misdemeanor which may
include a flue not to exceed ten thousand dollars ($10,000)-
Under penalty of law, J certify that (check all boxes to indicate your agreement)-
am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for anv civil or criminal penalties incurred due to violations of this
permit.
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 th(e 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.
F-1/ If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part I I of the permit are met on the project at all times.
I hereby req nest coverage under the NCGO10000 General Kermit and understa nd that coverage under
this permit wil I constittite the permit requirements for the d ischarge(s) and is enforceable in the
Same manner as an individual permit.
Name of Project: PN 0 U n e 171 Retrofit Receiver
Legally Responsible Organizational Entity: 1,�-
Legally Responsible Person: C_Zl�s1+��rtf
Title of Legally Responsible Person: -)^
*Signature: Date, 1 71
*Print Name and Title of Signed if Auffiorlred
Indivldrlal offers from Permittee;
Phone dumber.
* IMPORTANTNOTr . This form racist be slgrredby a responsible corporate officer rho# owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a rnonager that is
authorized in occordonre with Dart IV, Ser-Non8, Item (6) of the IVCGOI0000 permit,
For mare infor'mallor; on signatory requirements, see Part IV, Section 8, Item (6j of the NC 010000 permit.