NCC202720_NOI Signed Certification_20200626

NCGO1 Notice of Intent (N01) Certification Farm
Dirctians:
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00 NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BFFN
REVIEWS ❑ AND ACCEPTED AS COMPLETE.
APr !YC Grnwot SrohRr 1 aJ• 11 S. 68 JiA wry PWSM Who hire a'>0 4 00drs any 10he statrrrrrn r, represrn tativn,
or certfrr00" a3 air appknr vr; ^Kant rrvat pjWk or GdW doru"wnr filed or required to br mcwnra+ned
undff fM Ank* or a rL* xnprr++mf nq rhea Art+cAr sko br fTwny of a Clout 2 ndsdrrnronor whAch mar
►nrkm* a fine rear to r rred fro thousand dafars (SlaOM).
Under pinatty of law, 1 certify that tcheci eN boxes to WmWate your 6Rr��nt}
"fr/ 1 am the person reUlmons+ble far tier construction activities of this Protect, fore satisfying the
reQuirements of this permit, and for any crud or criminal penatties sncurred due io violations of this
permit
The informawn submitted in this Nol is, to the test of eery knowr4dge and belief. true, accurate. and
Complete based on my inquiry of the person or persons who manage the system, or those persons d�
directly responubie for gathering the information
l will abide by all conditions of the 90 10000 W010f fm-t and the approved Erosion and
Sediment Control Plan.
N the approved Erosion and Sediment Control Pion is not compliant with Part 11 (Storm water Pollution
Prewrtrition Plan) of the NCWIQM neraI Perm t, I wall nonethekis ensure that all conditions of
Part II of the permit are met on the pro)ed at all times.
I/ I hereby request coverage under the gGoJ,QM General Pt(ma and understand that coverage under
this permit will constitute the permit requirernents for the dhcharW%) and is enforceable In the
same manner as an individual permit.
Name of
L&gaay Responsible Or anitaWnal Ent
al?y Responsible' Person:
Title of Legally Responsible Person
'S+snatur
'Print Name and Title of 1/Authorued
a Q -
- Waal 'MO.
lndrodualyerrs�(rarrl Permitter:
Phone Nornber- � `7 ��1 t 10
IMPORTANT VO rf: This f arm must be s►gntd by a responsrb a cogw0fr officer that owns a operates the
constfW)on od1wry, slxh as a president, secretory, treasurer, or vKe pirrs►[fent, or o manoger that is
outhonzed in occordance with Part IV, Section 8, Item jbj o9 the NCG010000 permit.
For more information on signatory requirements. see Part IV, Section B, item (6) of the NCG010000 permit