NCC202087_NOI Signed Certification_20200520

NCGUZ Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scarf and upload to the electronic NiOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral 9 Land Resources Stoi-rnvvater Program
5.12 SalislDury Street, 6111 Floor (Office 540K)
161.2 IVtail Service Center
Raleigh, IBC 2.7699--161.2
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Pe)- NC General5totute A43-215.0 (i), any person who knowingly makes any false statement, representation,
or certification in any opplicotlon, record, report, plan, or other docu�-ne t filed or required to he mulotained
under this Article or a role implementing this Article ... shall he guilty of a Class 2 misdemeanor which may
include o fine not to exceed tern thousand dollars ($10,000).
Under penalty of law, i certify that (check all boxes to indicate your agree.rnerrt):
I am the person responsible for the construction activities .of this project, for satisfying ille
regr.iirements of this permit, and f o.r any civil or uirninal penalties incurred due to violations of this
permit.
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 sysieni, or those persons
directly responsible for gathering the information.
I will abide by all conditions of the IVCG010000 General Permit and the approved Erosion and
� Sediment Control Plan.
N If the approved Erosion and Sediment Control Plan is not compliant vlQlz Part II (Storil]uk+ater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
�f Part 11 of the permit ai-e met on the project at all tines.
C I hereby request coverage underthe NCGO10000 General Permit and understand that coverage under
this permit will constitute the pern-iit requirernerIts for the discharge(s). and is enforceable in the
same manner as an individual permit.
Flame of Project: 0710 a A ouq
Legally Responsible Organizational Entity:
Legally Responsible Person ilo" wome' -
Title of Legally Responsible Person: {y�--
3c5igriature: Date: S� ` 'lo )-0
':Print Name and Title of Signed if Authorized
Individual Differs from Perrnittee:
Phone NUMber: } 6(a-1 f i `,
* by a respornsil fe Corporate officer that Owns ar opero-TE5 the
1 president, r
rnr+5 tructiol oci.ii ,ii such as o f esideni, secre`or'y '-r-PHIS V:•, rr mice pr'e5k erat, or a rrrcinc�cr ilnaf is
authorized in occordonce vdith Part W, Section u, Iten" (b) qf the h1 G'0 f0000 permit.
For rtnr.,re inform atioo Oil signa ory re"), r.rircrn =arts see Port hV sec iorj B, item (5) of the NCG010000 peril -,it.