NCC202024_NOI Signed Certification_20200515

NCGO1 Notice of Intent (NO[) Certification Form
Directions:
Print thisform, complete, scan and upload to the electronic NOI.
Then, mail the original farm to the NC DEKALR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, & Floor (Office 640K)
1612 Mail Service Center
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 143-215,6E (i), uny person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed 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 fine not to exceed ten thousand dollars ($10,000).
Under penalty
penalty of law, i certify that (check all boxes to indicate your agreement):
i� 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.
N( 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,
( I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
/ Sediment Control Plan.
R It the approved Erosion and Sediment Control Plan is not compliant with Part II (Storrnwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part li 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 discharges) and is enforceable in the
same manner as an individual permit.
Name of Pro:iect: "Andn k1 !° da.P , Ph aJ4 3 - a(0 tS 1 Q
llv Responsible Organizational Entity: H F fl
Legally Responsible Person: lriaan Woll� _
Title of Legally Responsible Person: �`atn+
*Signature: Date: ---
"Print Name and Title of Signed if Authorized
Individual Differs from Pennittee:
Phon.eNumber: 0'146(0-96(04
IMPt?RTI- NT NOTE-: 77lis form t7lust Ise signed by o r-espor7sih)e corporate officer that otains or operates t17e
construction activity, such as a president, secretary, treasurer, or vice president; or a mananer that is
authorized in accordance with Part I1/, Section B, Item (6) of the Id0001000:0 permit,
ror more information on signatory requirements, see Purt Jl/, Section B, item (6) oj" the NCG010000 perrrrit.