NCC202523_NOI Signed Certification_20200617

NCG01 Notice of Intent (N0I) Certification Form
Directions:
Print this dorm, c_omplate, scan and upload to the electronic: N01.
Then, snail the original forrii to the NC DEMI_11 Sto-i-n-1 +ater Program (with $100 cheek if paying by check) at:
Division of Energy, Mineral 5, Land Resources StormwaW Progi ml
5U- N. Salisbury Street, 6'� Floor (Office 64OK)
1612 Mail Service Center
Raleigh, NC 27699--1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE---
Pet-NC Ge n eral Stat Lite 143-215.68 (i), ony person who knowingly makes any false statement, representation,
or certification in 017y application, record, report, plan, or other document filed or required to be rociotcrined
under this Article or a rule impler prating this Article ... shall he guilty of a Class 2 misd.emeonor- vibich may
include a fine not to exceed ten thousond dollors ($10,000).
Under penalty of lave, I certify that (check all boxes to indicate your agreement):
5( 1 ant the person responsible for the construction activities of this project, fov satisfy+ing the
requirements of this permit, and for any civil or criminal penalties Incurred clue to violations of this
permit.
The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
complete }cased on my inquire ofthe person or pel-sons who manage the sysiern, or those persons
directly responsible for gathering the information.
Lam` I wHI abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
lithe approved Erosion and Sedinien,t Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all candiiions of
Part II of the permit are met on the project at all times.
I hereby request coverage undel' the NCG010000 General Permit and understand tl7at coverage under
this permit will constitute the Hermit requirements for the discharges) and is enl=orceable in the
Same manner as an inclMdua.l permit.
Name of Project: —n-,i-e -xpw
Legally iJesponsible Organizational Entity: H H Co
Legally Responsible Person: Inf4t�I�� - Title of Legally Responsible Person: pr( cn+
5
Date; S�1 �f /20Zf7-
*Signature: _
*Print Nan,xe and Title of Signed if Authorized
Indivirluol Differ-S fr or77 Pei'r7,ittee: _
Phone Number: 110
M tPOR 1 hi.s form mugit be sighed by o responsible cor1.7orcIfe officer that 01/tr175 Or olaer'ai`C, i he
CCtnSb trction eciiVitJ, srJdr as o prrrsiYer� ; sr'cre"00J ?-rcosure+', rr rice l7residet7r, or e r7TOOP!7Cr that is
GOtlrorized in accc�r'doace urir':h Part It/, Section L, Item (5) ni`tbe 1VCG010000 perr,7i .
c7r rr7r re lrlforr77r °ia�7 Ur7 signatory ret,rJ1rcr7'iet7is, see F'ar i ll; Sc:ctiar7 B, Item (6) of the i EG01Cr000 per'nllf•