NCC202319_NOI Signed Certification_20200604

NCG01 Notice of Intent (N01) Certification Form
Directions,
Print this form, complete, scan and upload to the electronic NOL
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division ofEnergy, Mineral & Land Resources StonnwaterProgram
512N. Salisbury Street, GmFloor (Office 64OK)
1612Mail Service Center
Raleigh, 0[Z7699'161Z
DO NOT MAIL THIS FORIM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute, 143-215.613 (i), any 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 urorule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include ofine not 10exceed ten thousand dollars /$2Ll000/.
Under penalty of law, I certify that (check all boxes to indicate your agreement):
,XJ !amthe person responsible for the construction activities ofthis project, for satisfying the
requirements of this permit, and for any civil orcriminal penalties incurred due toviolations ofthis
permit.
X1 'The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
cornplete based on niy inquiry of the person or persons who rrianage the system, or those persons
directly resprnsib!efor-atheringthe information.
XIJ iwill abide byall conditions ofthe and the approved Erosion and
Sediment Control Man.
X1 if the approved Erosion and Sediment Control Plan is riot compliant with Part 11 (Stormwater Pollution
Prevention Plan) ofthe KGO1,0000 General Permit, | will nonetheless ensure that all conditions of
Part !iofthe permit are met onthe project utall times.
| hereby request coverage under the NCGO1,00001 General Perrnit and understand that coverage under
this pert -nit will constitute the permit requirements for the discharge(s) and is enforceable in the
same manner asanindividual permit.
Name of Project: 7-Eleven at Northlake West
LegallyVenture Construction CompanV
Responsible Person: Sean Smith
Title of Legally
Mana
Aer
*Signature: A— Date: 5/22/2020
*Print Name WAuthorized
Individual D from Permittee: N/A
Phone Number: 901-870-0104
*IMPORTANT NOTE.- This form must be signed by a responsible corporate officer that owns or operates the
construction act. ivity, such os a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 permit.
For more information onsignatory requirements, see Part IV, Section B,Item (6) of the NCGO10000 permit.