NCC202473_NOI Signed Certification_20200615

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, cornplete, scan and upload to the electronic. N01•
Then, n"rail the original form to the NC DENII_R Stormvmter Program (with $100 check if priving by check) at:
Division of Energy, Mineral i s Land Resources Stormwater Pr-ograill
512 N. Salisbury Street, 6"' Floor (Dffice 64010
1.612 Mail Service Center
Raleigh, h1C 27699-161
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143--215.68 (i), ony person who knowingly makes oi-iy jolse. stoternen. ; represen totion,
or certification ir7 ony:application, record, report, plati, or other document filed or required to be n-mintained
udder" this article or u rule implementh7g this Article • .. shall be guilty of u Cross .2 misdemeanor which mo. ),
ir7ciude o fine not to exceed tern thousand doll.ors ($10,000).
Under penalty of law, i certify thai (check all boxes. to indicate your agreement);
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.
The information submitted in this NOi is, to the hest of nay Imcwledge and belief, true, accurate, and
complete irsed on nay 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 NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
if the approved Erosion and Sedin-lent Control Plan is not compliant with Part II (Storrziwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understand that coverage under
peni�ii udill car�stitute tl�e perri�it requirements for the discl�arg-{s) and is enfo "ceaI I in the
sane manner as an individual permit.
Marne of Project;
Ahd.r rsa nCrttX CIO
{Jodi The 1+ut Um Ph a.. c-e.'l , d-ec"F o-vi 2C
Ili! Responsible Organizational Entity
Legally Responsible Person: lri& t waltw '
Tit#e of Legally Responsible Persor:
*Signature:r ` " - [late: Sl j l Zp
"Print Name and Title of Signed if Authorized
indiyiduol Differsfrom Permit -tee.
Phone NUMber; 11 0 - "t 6G-q' X
[AIM0R i AN NO i I : i IrisIorrn Just Ise Signed by a responsil)la corporate officer ihot c rims nr operates the
r r �- r rrr t ! r
Cf1n�tJ"ZrCIlo11 Gc.l.r4.ftJ, 5.;..11 f_s C i-f•E.•1L��11(� 5P.C1"P_tuI"S, t7'eCX,StIl"er", GI-rliCL' i�3r�Sli:?en[; G!' o mmf;(7pe!'thotl.S
authorized in occordonc-c- v11,ih Port A/, Secti.ol7 P, Item (b) of the
For Mrs -re see Purl ll/, Section B, lien (6) pi -h NCOO10000 i�errrii •