NCC202160_NOI Signed Certification_20200522

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral an Resources Stormwater Program
512 N. Salisbury Street, 6°i 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 143-215.68 (i), any person wlio knowingly makes anyfalse statement, representation,
or certification in any application, record, report plan, or other document filed or required to be maintained
udder 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).
Und�e/r penalty of law, I certify that (check all boxes to indicate your agreement):
M 1 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.
5( 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 system, or those persons
directly responsible for gathering the information.
L�1 I 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 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
L� I hereby request coverage under the NCG010000 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 jaern-lit.
Name. ofProject RS�4 N f M dPpvd-.Cott 29�j�30q, 312,3t3r315.319-3�1
� 3�2 r333
Legally Responsible organizational Entity: "iAC�OtS�Ty�C
Legally Responsible Person $riotn WaltCe
Title of Legally Responsible Person: Pram+
Date:
`Print Name and Title of Signed if Authorized
Individual Differs from Permiitee:
Phone Number: 1/ D "' 'I UG"-1 U(a4
" IMPQR7ANPNOTE; This form
must be signed
by a responsible
corporate officer that ov✓ns or operates the
construction aci_ivity, suds as a
president; sen'etar7, treasurer,
or vice president, or n manager that is
authorized in accordance with
Part IV, Section
8, Item (6) of the NCG010000 permit.
For mare information on signatory requirements, see Part IV, Section 8, Item (G) of the IVCG010000 peniiit.