NCC201568_NOI Signed Certification_20200526

111
IMCGO1 Notice Of Intent (NO) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic N01,
Then, mall the original form to the NC DEMLR Stormwater Program (with $:1.00 check if'paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
S17 N. Salisbury street, Wh door (office 640K)
1612 Mail Servfce Center
Raleigh, NC276994612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS KEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation,
or certification in any appilcation, 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 afine not to exceed ten thousand dollars ($10,000).
Under penalty of law,1 certify that (Check all boxes to indicate your agreement):
I am the person responsible forthe construction activities of this project, forsatfsfying the
requirements of this permit, and for any civil or criminal penalties Incurred due to violations of this
part -nit.
The information submitted In this Not is, to the best of sny 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 gatheringtheInformation.
lg1 I will abide by all conditions of the NCG010000 GRneralPermit and the approved Erosion and
Sediment Control Plan.
XJ If the approved Erosion and Sediment Control Plan Is not compliant with Part: It (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit ara met on the project at all times.
® 1 hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permlt will constitute the permit requirements for the discharges) and Is enforceable in the
same manner as an individual permit.
Name of Project: Stroud En lneering Office
Legally Responsible Organizational .Entity: Stroud Engh)eering, PA
Legally Responsible Person: Linwood Ls, Stroud
Title of Legally ResloQWSIble Persnrr: Presiclas �
Print Narne and Title of Signed If Authorized
Individual Dffferg from PermJttee.
Phone Number: [phone]
1Mp0RTA1V;rN0TC; Thisfarm must be signed by aresponsible corporate officer that owns or operates the
construction activity, such as a president-, secretary, treasures; or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO. 0000 permlt
For more Information on signatory requirements, see PcfrtlV, Section 8, Item (6) of the NCGG10000 permit,