NCC202074_NOI Signed Certification_20200519

NCGO1 Notice of Intent (ND#) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01.
Then, marl the or grnal Form to the NC 0EMLFt 5tormwater Program (with S100 check if payrng by check) at:
Division of EneM. Mineral a land Resources 5tormwater Program
512 N. 561Fsbury Street, 6t" Floor IQf}ice 640K)
1612 Mail Service Center
Raleigh, NC 276"-1612
DO NOT MAiL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-21S 68 (i), any person who knowingly makes any false statement, representation,
x certification in any appl,catron, record, report, plant, or other document filed or required to be maintained
ender this Article or a rude implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
nclude ❑ fine not to exceed ten thousand dollars ($10.000).
Inder nalty of law, i certify that (check all boxes to indicate your agreement):
7I 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.
211/ The information submitted in this Nol 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 wi11 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 11 (5tormwater Pollution
Prevention Plan) of the NCG010000 General Permit, 1 will nonetheless ensure that all conditions of
Part I1 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 discharges) and is enforceable in the
same manner as an individual permit.
ne of Project: �Q,r'f-'Ad �lrn S
ily Responsible Organizational Entiti
;ally Responsible Person: ,
Z�aero—
Title of Legally Responsible Person: o(rlrrle +&
*Signature:
'Print Name and Title ofSYgned if Authorized
individual Differs from Permittee:
Phone Number: qu)
Date:
* 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 B, item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.