NCC201629_NOI Signed Certification_20200501

NCG01 Notice of Intent (I40I) Certification Form
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Directions:
Print this form, complete, scan and upload to the electronic N01.
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, 61 Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR P,AYMENI UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-21S.6B (1), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document fried 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 a flee not to exceed ten thousand dollars ($10,000).
Under enalty of law, I certify that (check all boxes to indicate your agreement):
[ 1 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 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 ablde 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 II (Stormwater Pollution
Prevention Plan) of the NCGO100DO General Perm) I will nonetheless ensure that all conditions of
art Il of the permit are met on the project at all times.
I 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: A/A 1/'L -rkt j ;`. sT,11'A YM I �OT I a N
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Legally Responsible Organizational Entity: tt el J�;N dill awl"JivreL 7?:.r'Y1 -9WtS AN 0
Legally Responsible Person: TI i% Y14 01 S rL is G'7YV S-r) Ur'rl ofV/ ► ry 4
Title of Legally Responsible Person: 'fv
*Print Name and Title of Signed if Authorized
Individual Differs from Permittee. T 1"'1
Phone Number:
Date: YI'-ZOZts
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* 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 manager that Is
authorized In accordance with Part IV, Section 8, Item (6) of the NCG0100W permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.