NCC201867_NOI Signed Certification_20200508

NCG01 Notre of Intent (NOI) Certification Form
Fru" oft fto aa4 Win- v. mm and wb•d to the etectrnrAc Not_
Yam. Wag WW arWbW 0m, Imo the IWC 0[M tX S0W1r.r ate+ Probrvm (With Slob d*ett 1 parng by check) at:
DM%iom of E "Veep, &%W#W ■ Lend 11eiolrrtr1 5twmwalrt Pf"tem
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140040 � t11C ? ft" 1611
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
RrviFWF.D AND ACCEPTED AS COMPLETE
Per MC Grn&* Statute 143-215." (t), any penon who tnowkVIV makes any false statement, representation,
or cerraj kwoon on ony aypphcotkv% rft-ord. report;, pion, or other document filed or required to be maintained
un&*r this ArticAr or a rde *yq*nwnhng this Article ... shall be guilty of a Class 2 misdemeanor which may
inc&* a tine not to exn*ed ter, thousand dodoes ($10,000).
Under penafty of law, I certify that (check all boxes to indicate your agreement):
2 lam 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.
2+ 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 system, or those persons
directly responsible for gathering the information.
Z' 1 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 it (5tormwater Pollution
Prevention Plan) of the NCG010000 General Permit I will nonetheless ensure that all conditions of
Part If of the permit are met on the project at all times.
;,/ 1 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: Oa 1LfT 1O(4 su t)'yi 6r'L
Legally Responsible Organizational Entity: jj�Q_dM�
Legally Responsible Person. knreu L I,'k\j.Q_F a -
*Print Name and Title of 5
ed if Authorized
Individual Differs from Permittee:
Phone Number:
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 1V, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.