NCC201749_NOI Signed Certification_20200501

NCG01 Notice of intent (NO1) Certification Form
Directions:
Print this form, complete, scan and uptoad to the electronic N01.
Then, mall the original form to the NC DFMI R Stnrrnwater Program {with Sloo check if paying by check) at:
Dlvislon of Energy, Mineral R Land RPSOur(es Starmwater Program
512 N. Salisbury Street, 6"' Floor IDHIce 640K)
1612 Mall S@rvke Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL UR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED j}
Per NC General Statute 143-215.60 0), any person who knowingly makes any false statement, representation,
to b
or certification in any application, record, report, plan, or other document Pled
r required
demeanomisr aintai y
ned
under this Article or a rule implementing this Article ... shall be guilty of s
include o fine not to exceed ten thousand dollars ($10,000).
Linder penalty of law, I certify that (check all boxes to indicate your agreement):
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.
[+f The information submitted in this NOl 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/ I will abide by all conditions of the NCGO10000 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 NCGO10000 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 NCG010000 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: 31-L
R
f Responsible Organizational Entit,
Ily
Title of
3onsible Person: A41AS-C.� lZ
3onsible Person: ' 11
*Signature:
*Print Name and Title of 94ed if Authorized
2
Individual Differs from Permittee:
Phone Number: 9 d' S —
IMPORTANT NOTE: 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 monager that is
authorized in accordance with Part IV, Section B, item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, item 16) of the NCGO10000 permit.