NCC202036_NOI Signed Certification_20200701

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print th.s form, complete, scan and upload to the electronic NDI.
Then, mail the original form to the NC DEMLR 5tormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. 5aiisbury Street, 6" 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
Per NC Generni Statute 143.215.68 (if, any person who knowingly makes any false statement representation,
ar certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or o rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
incl11'am
of to exceed ten thousand dollars ($10,O00).
Linof law. I certify that (check ail boxes to indicate your agreement):
he person responsible for the construction activities of this project, for satisfying the
re
irements of this permit, and for any civil or criminal penalties incurred due to violations of this
7ermit.
The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
com ete based an my inquiry of the person or persons who manage the system, or those persons
,,directly responsible for gathering the information
I wil abide by all conditions of the NCGQ10000 General Permit and the approved Erosion and
diment Control Plan,
If tine approved Erosion and Sediment Control Plan is not compliant with Part 11 (Storrnwater Pollution
Pre ntion Plan) of the NCGO10000 General Permit 1 will nonetheless ensure that all conditions of
rt II of the permit are met on the project at all times.
I hereby request coverage under the NCGf110000 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:
E $ AT- 'p'- Eo w F-Gie kC 7-i24
r i
Legally Responsible Organizational Entity: [?H fj-1�>=Ep �IC LL G
Legally Responsible Person: '-FrFr UJh,
Title of LWIly s nsi son: ir►�G�
`Signature. UTUDate:
*Print Dame a Title of Signed if Authorized
Individual Differs from Permittee:
Phone Number: 1 q,?)-S7gZ
'IMPORTANTNOTE. 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
outhoriied in accordance with Part IV, Section E, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.
i N �a