NCC202170_NOI Signed Certification_20200522

NCGO1 Notice of Intent (NOB) Certification Form
7107pff", "I
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NCD8N0StonnwaterProgram (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StunnwaterProgram
51ZN.Salisbury Street, GmFloor (Office 640N
1612 Mail Service Center
Raleigh, 0CI76Q9'16l2
DO NOT MAIL THUS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per �General Statute 143-215.6B (i),mny person who knowingly makes anyfalse statement, representation,
or certification in any application, record, report, plan, or other documentfiled 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 ofine not toexceed ten thousand dollars /$2(lO0D/.
Under penalty oflaw, | certify that (check all boxes toindicate your agreement:
' |amthe person responsible for the construction activities ofthis project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
$4- 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.
} will abide byall conditions nfthe NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
if the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) ofthe | will nonetheless ensure that all conditions of
Part ||ofthe permit are met onthe project atall times.
�Z |hemby 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 asanindividual permit.
Legally
Title of Leizallv ResDonsible Person: President
*Signature: Date:
*Print Name and Title 4signed if AlKorized
Individual Differs from Permittee:
Phone Number: [phone]
*IMPORTAN7NOTE. This form must be signed byoresponsible 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 Port IV, Section B, Item (6) of the NCGO10000 permit.
For more information omsignatory requirements, see Part IV, Section f, Item (6)ofthe N[G0 0000pennit,