NCC202722_NOI Signed Certification_20200626

NCG01 Notice of Intent (NDI) Certification Form
IDi rectbAs:
Peter ttosao�W, Scan and upload to the elrctronk NOI
That. mall Itio or10 loin to tthe NC DE M[R Slorrm"'ler Program (with $Soo ctw k of payer by a*&) at:
00viiyot of tneM. ojft%wat Ill land lalources StorrnwAtrr Program
S 11 N 5ait 6Wy S1r9• 61 Floor (O"ko 640KI
1612 %W servicr canter
Raleigh, NC 2 7699 -1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Air ABC CWWVVW Stohrt+e !/1-113 68 ft any pnsan who k1aW11A94'M0AWs vise fclse ttarrmrnt represrntctiwr.
rrcorA report pbM or other docurrhent foAed or required to de rnointokwd
ufndlr t1w Arr * or a rule itWtrnhrnthrtq then ArrK* . - - slhoilf be purity of a Cross 2 m►sdenwancir which may
.rhrbA* o fnw not to exr"d tern thounond doilan (S10,01 Ii
Under penarty of taw. I ce►trfy that (Checik all boxes 10 indicate your lgreernent):
ism the person responsible for the construction activities of this project, for sattsfving the
requirements of this perrnit, and for arry civil or Criminal penalties incurred due to v►otatsons of this
permit
(' The information submtttrd m this NO[ is. to the best of my knowle-dge and belief, true, accurate, and
complete based on my inquiry of the person or Persons who manage the system, or those persons
diroctly responsible for gathering the information.
1 will abode by all conditions of the NCG010U00 Gt•rrdi Permit and the approved Erosion and
Sediment Control Plan.
F-1 if the approved Erosion and Sediment Control Plan is not compliant with Part II IiStormwater Pollution
Prevention Plan) of the NCGO10000 General Perm►L, I %nit nonetheless ensure that all conditions of
Part II of the permit are rnet on the project at all times.
I hereby request coverage under the NC1G410440 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.
Norge of tylct. �p�i. ►I &((fNs - _-Z o} 5 -4q _q a %% �QfM--a
We Organizational Entity,
Legally Responsible Person_
Title of L all Responsible Person:
'Sgnatu
• P►int Name and Title of ed if Author+red
Individual DdersPermittee
Phone Number- 9/
Date:
' IMPORTANT NOTE: Fbis form moist be signed by a respons►bAe torpa►ate officer [hat owns or operates the
construction acirvit), such as a president, secretory, treasurer, or vice president, or a manager that is
outhorued in accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit,
For mare information on signatory requirements, see Part IV, Section 8, Item (6) of the NCG010000 perm,t.