NCC202547_NOI Signed Certification_20200618

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
S12 N. Salisbury Street, 61 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 "! COMPLETE
Per NC General Statute 143-215.68 (i), any person who knowingly makes ony false statement representation,
or certification in any opplication, record, report plan, or other document flied or required to be 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 penalties incurred due to violations of this
permit.
C� The information submitted in this NO1 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 all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Parr 11 (Stormwater Potlution
Prevention Plan) of the NCG01.0Ra0 General Permit, I will nonetheless ensure that all conditions of
Part I of the permit are met on the project at all times.
1K I hereby request coverage under the .o-GO10000 General Permit 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: F— l e �� R (ACYl
Legally Responsible Organizational Entity: '
ie -7 CA fner
Legally Responsible Person: Ue r
Title of Legally Responsible Person: H n m P r,,v J n r—r
re:
*Print Name and Title 9f Signed if Authorized
Individual Differs from Permittee:
Phone Number: 7C.-; . _ ()
Date:
II
* 1MPORTANTNOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president or a manager that Is
outhorized in accordance with Port IV, Section s, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10W0 permit.