NCC201782_NOI Signed Certification_20200501

Print this form, complete, scan and upload tothe electronic N0'
Then, mail the original form to the NCDEMLR Stormwater Program (with $100check ifpaying bycheck) at:
Division ofEnergy, Mineral & Land Resources StnrmxaterProgram
5120.Salisbury Street, 5mFloor (Office 64DK)
1612 Mail Service Center
Raleigh, NC2769Q-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NCGeneral Statute 143-215.680lany person who knowingly makes any false statement,
or certification in any application, record, report, plan, or other documentƒled or required to be maintained
under this Article nrorule implementing this Article ... shall beguilty qfoClass 2misdemeanor which may
include o/inonot tsexceed ten thousand dollars ($10,000).
Under Apnabyoflaw, | certify that (check all boxes toindicate your agremment:
!amthe 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
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,
Iwill abide byall conditions ofthe NCGO10000 General Permit and the approved Erosion and
8edicnentControiP|an
�� .
�� |ftheapprovedErosionandSedimentComtno|P{anisnctconopUantvvb6Part||(StonnwaterPo|lutian
Prevention Plan) ofthe NCGO10000 General Permit, | will nonetheless ensure that all conditions of
Part |}nf the permit are met onthe project atall times.
| 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 ofPruiect:
zonsb|ePeruzn:
Title ofLcgek/Responsible Person:
*Signature: __
*Print Name and Title ofSigned /fAuthorized � ) _J �
����D��f���h�: �/o� �.
*IMPORTANT NOTE.- This form must 6esigned bvo responsible corporate officer that owns oroperates the
construction activity, such asopresident, secretary, treasurer, mvice president, momanager that is
authorized inaccordance with Part IV, Section B,Item (6)ofthe NOG01O00Dpermit.
For more information on signatory requirements, see Part IV, Section B, Item (6) ofthe /V[GDJD0O0penn/L