NCC202524_NOI Signed Certification_20200617

NCGO1 Notice of Intent (NOI) Certification Form
Directions: 1
Print this Form, complete, scan and upload to the electronic NOL
Then, mail the origin@I form to the NC DEMUR Stormwater Program (with S100 check if paying by Check) at:
Division of Energy, Mineral & Land Resources 5tormwatcr Program
512 N. Salisbury Street. 6t' Floor (Office s40K)
1612 Mail Service Center
Raleigh, NC 27,599-1612
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), any person who knowingly makes any folse sratemer?� representation,
or certification in any application, record, report~, plan, or other document filed or required to he maintained
Under this Article or a rule implementing this Article - .. shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed tern thousand dollars ($10,000).
Under penalty of law, I certify that (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 penatdes incurred dole to violations of this
permit.
%% The information submitted in this NO[ 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.
will abide by ail conditions of the. N ci DQgo ener l P rmit and the approved Erosion and
Sediment control Plan.
If the approved Frosion and Sediment Control Plan is not compliant with Part li {5tormwater Pollution
Prevention Plan) of the NCGQIQM Qener4l Permit I will nonetheless ensure that all conditions of
Part a of the permit are met on the project at all times.
i I hereby request Coverage under the NCG410000 Genera, Permit and understand that coverage ur�clrr
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 1'-'(+�et c�,r
Legally Responsible organizational Ent' t n i ►r,-
Legally Responsible Person ---
Title of Legallyponsible Pe
Date: (o - I I - . c'
`Print Name and Title of Signed .i# Authorized _
Individual Differs from Permittee: _ cti, i t� C.
Phone Number: '� & - L 0 -
" IMPORTANT NOTE: This form must be signed by a responsible corporate of f cer that awns Or Operates the
construction acrivrM such as a president secretary, treasurer, or vice president or a manager that is
authorized in accordance with Part 1Y, Section 8, item (6) of the NCGO10000 permit.
For more information on signatory requirements. see Part 1V, Section 8, item (6) of the NCGO10000 permit.