NCC201815_NOI Signed Certification_20200504

NCGO1 Notice of Intent (I I) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, maii the original farm 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 27699-1512
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per fVCGeneral Stotute 143-215.66 fij, ony person who knowingly makes anyfal,se statement, representotiorr,
or eertiffcofion in any appUcution, record, rep art, plan, or other dacument filed or required to be maintained
under this Afticie or a rule implementing this Article , .. shoil be guilty of o Class 2 misdemeanor which may
include a fine not to exceed fern thousand dollars ($10, ).
Under 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 incu rred due W violarior�s of this
permit.
The information submitted in this N01 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 systern, or those persons
directly responsible for gathering the information.
s I wil I abide by al I conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erasion and Sediment Control Plan is not compliant with Part II (Stormater Pollution
Prevention Plan) of the NCG010000 General Permit I wil I nonetheless ensure that all conditions of
Part II of the permit are rrreton the project at all times.
I hereby request coverage under the NCG010000 General Permit a nd understand that coverage under
this permit will constitute the permit requirements for the discharge(s) a nd is enforceable in the
same manner as an individual permit,
Name of Project: PNO Line 171 Retrofit Launcher
Legally Responsible 0rganiaationaI Entity. PNka "'+ V4
Legally Responsible Person: .+ A 0 av'm
Title of Legally Responsible Person: y ?
*Signature;
*Print Name a rid Title of Sig r)ed if Authorized
Individual Differs from Permittee:
PhoneNurnber: (--7C4�1 I
4Q-4u
Date: I Z-712-0-6
*IMPORTANT NOTE. This form rrrost he signed by a responsible corporote officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice pre5idenr, or a monager that is
authorized in accordance with Part IV, Section B, Item () of the WG'010000 permit,
For mare information on signatory requirements, see Part IV Section 8, Item (6) of the NCG010600 permit.