NCC202727_NOI Signed Certification_20200629

NCGO1 Notice of Intent (NOI) Certification Form
Purr ttws loan_ cote Wk @,. wan and uphu d to tho 04KU W MOt
Than, ""d the arlgrn A form to the W IX W% Saormrwtrr Prog win twat+ S 100 cMrtk Of papwv by check l au
Orrrrspn or f nar=y, k www ■ tw w ft"Mirrn ftwmwaw Program
S 11 N Sa61lurt► S""Pt a noat low" GAM)
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DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Pw MC Grrwar sta t4f J114"1 s "4 m►y Per 40 wr a iftftw gllr "roars any loom s to rernent< rrprrsen tat►on,
o'r cc"%n*a^ M N!' C l ►rtiCW report Pbn or other docurrtprt/Med or requPred ro be nsomfaned
wtdw rna Afhc* Or e n4 Nrytlerew 0" Oft AMC* slsa+r be ,putil[y of a Cllass ? misdemrarnor which may
MWAN le a txw not to ewwd trw to 0 - a %rwwn (pa0w)
Under of im, f COMOy that jcfwk a* Gores to indicate pour &Srtemcnt}•
tht psreon r"Oonsr6le for the construction activities of this project, for witsfying the
rrqurerrsrnes of this permit, and for arty Nrtl or adrrtinal penalties incurred due to violations of this
permit
V the information subm►eted in this NOI is, to the best of my knorvled" and belief, true, accurate, and
comPAMe based on my inqutry of the person or persons who manage the system, or those persons
d,rectty reWnsttsie for Sathennd the informal ion.
I wim abide SY ail conditbns of the NCG0jQQQQS&rjr4l p rrv), and the approved Erosion and
Sedwrrrnt Control Plan
If the approved Erosion and Sedirmmil Control Plan is not compliant with Part II (Stprmvrater Pollutson
Prevention Plan) of the tKWI01)[](3Permit_ I rnll nonetheless ensure that all Conditions of
art 11 of the permit are met on the project at a6 times.
1d 1 hereby request coverage under the H r I PC f m It and under
itar>d that Leverage under
this permit will constitute the permit requirements for the discharge(s) and is enforceable to the
same manner as an ,ndrviduai permit
Name of Project: R "e-k -t
Lqalf� nstbfe Q nrrational Ent'
J9J OY Rtspon%N* Perrson I
1
Titleof Legolt�r rns,bk Peryvn „t�l.L �^
i
Date:
'Print Name and Title of Sig4d yAulhorired
Irsdmduol Dr ere jram Permrttrr:
PHorwe Ntunber: ���
i4TAlVTAIQTF: This Jim must be signed by o respo►hsibk c
co�nstfuctro►n Xtrvity, such as a prrsrdrn(, Serre(O treasurer a air officer ihor awns ar operates [ter
rl+• president, or a manager [hat is
author►red in arrarrJorrce write Port >V Section 8, lttm (b) o/ the NCG0I0000 permit.
For more rn/amQtiOn On signoto y requirements, see Part IV, _, 7Oa r 8, Item jb j Of the NCGOI0000 permit