NCC202300_NOI Signed Certification_20200603

NCG01 Notice of Intent (NQI) Certification Form
I Directions:
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DFMLR Stnrmwater Program (with 51Of) rherk if payinq by rherkj at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Strut, 6" Floor (Office 640K)
1612 Mail Service Canter
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HA-5 BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 14.3-215.68 (i), any person who knowingly makes any false statement representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implevmenting this Article ... shall be guilty of ❑ Class 2 misdemeanor which may
include o fine not to exceed ten thousand dollars ($10,0W)7
Under penalty of law, I certify that (check all boxes to indicate your agreement):
i/ I 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.
i, The information submitted in this N01 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 will abide by all conditions of the NCGO1GDOU General Permit and the approved Frosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part Il (Stvrmwater Pollution
Prevention Plan) of the NC15OtQQI}0 CtienPral Pt:rmit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharge(sl and is enforceable in the
same manner as an individual permit_
Name of Project: Z,04 .57 Al
Legally Responsible Organizationai Lntlty:.',--
TLmalty Responsible Person: %c a is - 7&rrrw3Q� _
Title of Legally Responsible Person:
*Signature: -� � - - Date:
*Print Name and Trice of Sig4d if Authorized
Individual D►ffers from Perrnittee:
Phone Number: 91. '-SaCZ
IMPORTANT NOTIr- This form m"sr be signed by a responsible corporate offirer that nwm or npAratP5 the
construction octivrty, such Os d president, secretary, treasurer, or vice president, or a manager that is
authorized in acrordancP with Part IV, Section 8, item (6) of the NCG010000 perm►t-
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