NCC201752_NOI Signed Certification_20200504

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DFMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stornwater Program
512 N. Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Censer
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute .143-215.613 (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other- document filed or required to be rnaintained
under this Article or a rule implementing this Article ... shall be guilty of a Closs.2 misdemeanor which may
include a fine not to exceed ten thousand dollars (.$10,000).
Under penalty of iaw, I certify that (check all boxes to indicate your agreement);
t� 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.
i� 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 abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
N If the approved. Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 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 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: t5jh \.e Q- 1-D, CgCh oil FQyLr. Parr Tw.o - 2q -�9�, 308 -3�2 t, 3 >I
Legally Responsible Organizational Entity: H f � Go RS S
Legally Responsible Person: �C144rg Wlxlker
Title of Legally Responsible Person; p`am+
*Signature:,,, Date: 3-Y20 2-0
`Print Name and Title of Signed if Authorized
Individual Differs from Permittee,
Phone Number: 11 0 - 14 86-14 OVP
* 1iVt'9RtANT NOTE This form must be signed.Uy a responsible corporate officer that ouans or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance u/ith Part !l! Section 8, Item (5) of the NCGD7.0000 permit.
For mare inforrrratiOl on signatory requirements, see Part 1V, 5ectiar7 B, ken? (6) of the NCG0.10000 permit.