NCC202541_NOI Signed Certification_20200618

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print his form, complete, scan and ta,pload to the electronic_ i 01.
T lien, nail the origin a€ form to the NC DEMLR Stormwater Program (with $10o checI< if paying by check) at:
Division of Energy, Mineral 9, Land Resources Stortmvmter Program
512 N. Salisbury Street, 6;11 Floor Office 640K)
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
Pei' NC General Statute 143-215.68 (i), orgy person who knowingly mokes ciny false statement, representation,
or certification in any application, record, report, p0n, or other documelit f iled or required to be muiniail? ed
under.this Article or a rule irrrpleme:riti►tg this Article . , . shall be guilty of a Class 2 rnisdemeonor which may
include a fine not to exceed ter7 thousand dollars ($10,000).
Under penalty of late, l cerffy that (check ail boxes to indicate your agreement):
Q/ I am tile person responsible for the construction activities of this project, for satisfying the
mquirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
6( The information submitted in this NDI is, to the nest 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.
5 1 will abide by all conditions of the NCG010000 General Permit 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 NCGO10000 General Permit, I will nonetheless ensure the t ail conditions of
Part II of the permit are met on the project at all times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requiren-rents for the c,ischarge(s) and is enforceable in the
same manner as an individual permit.
Name of Project: jF4jjVVtr NDYM , s{(;h on jJnt�� Q flYle -,.( Di',;�0_��l (t,�.Tkv
Legally Responsible Organizational Entity: ! u►1�C"t�S ����wC . �" ° f �%
Legally Responsible Person: lean Walt('er'
Title of Legally Responsible: Person: J{--
*Signature.. `
� Date: 5 -,2iQ -ZO`LO
"Print Name and Title or Signed if Aothorized
Individuol Difr`er-s from Pen-oiitee:
Phone I10 - y 6(0-141Noy
* lCt�rCil?7't+:Itl! ftIC.91;r: this fora-i must he sighed by o.reslaarjsibl? crtlport7 e C)jfjCej-Chat orltirns nr oi)errs'cs' the
U)1')_` l GCL;Gn aCi:r!%?f l', such as Ci president, seer etCrr); treasC rer, of 4�If V prc-sloBilm; fil' a rl "Ilclge' 'that !s
cuthorized h-1 ccrcrdonce 11"'irh Part Al section 3, ltenT (6) Qf the AICGO-10000 pprri7k.
nor r�.�'re 1, 'or motion On Signatory requirements, see Pots W, SeC icrr �, .lLen,7 f6) of the NCGt710000 pet"relic`'.