NCC202370_NOI Signed Certification_20200605

f NCG01 Notice of Intent (N01) Certification Form
- � Directions:
Print this form, complete, scan and upload to the electronic NOI.
Thera, mail the original form to the NC DEMLR Stormwater Program (with $100 check if 0Ying by check) ar
Division of Energy, Mineral & Land Resources Stormwi ter Program
512 N. Salisbury Street, 60 Floor (Office 640K)
1612 Mall Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED • COMPLETE
Per NC General Statute 143-215 E9 (ix any Parson who knowingly makes any false statement representaVon,
or cerbYlication In any appacablon rr f o, d, .rVport, plan, or ocher document filed or required to be maintained
under this ArWe or a rule imptementing this Artkie ... shall be yuitty of a Mass 2 misdemeanor which may
bx*jd-- a fine not to eweed ten thousand doftm ($1v oW).
Under Lzr: arty of law, I certify that (check all boxes to indicate your agreement):
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.
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.
I will abide by aff conditions of the N al Ft f rith 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 - . ! General Per; i,!t, I will nonetheless ensure that all conditions of
Part Il of the permit are met on the project at all times.
i hereby request coverage under the NCG0I0000 Generale 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 permit.
Name of Project: J V1eCY t 1-4169U ff,-TUS LOT 61C 1 ?U--'-C-Aq06 ZV
Legally Responsible Organizational Entity: ilk-7D4Z-A MTn& -
Responsible Person:
Title of
LA-Tc9 i' U �-TTUS
Date: 5 - Zq - Z 0
*Print Name and TTItle of
if Authorized
Individual Differs from Permfttee.- j Q
Phone Number. �04 - iD`t" i ` -(7
t ri,
* lMP0hTANrlYf01E- This form must be signed by a respon-sole corporate offerer dW owns err operates the
constriction iy, such as a president, secretary, treasurer, or vice president or a manager that is
oudi3orited in accordance with Part IV, .Section B, Item (6) of the NC6010000 permit
For rrrore lnfWwx tian on signatory requ cements, see Part IV, Section B, item (6) of the NC601M)O permit