NCC202929_NOI Signed Certification_20200713

NCG01 Notice of Intent (NOI) Certification Form
Directions: i
Print this form,complete,scan and upload to the electronic NOL
Then, mail the original form to the NC D6MLR Stormwater Program (with$100 check if paying by check) at: j
I
Division of Energy, Mineral & Land Resources Stormwater Program !
512 N. Salisbury Street,6"' Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT i`AiL T HiS r ORIWi OR PAYMEVil- UNTIL YOUR kPPLICATION HAS BEEN
Per NC General Statute 143-215.69 (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report,plan, or other document filed 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 ten thousand dollars ($10,000).
, reer pen.a y of av, ; E. poxes to indicate your agreement):
am the perm Tor the construction activities of this project,for satisfying the
-eq� remer:`_ and for any civil or criminal penalties incurred due to violations of this
oermit.
Tre'inform__' _ bmitted in this i`i01 is, to the best of my knovi.''edge and belief,true,accurate, and
inquiry of the person or persons who manage the system, or those persons
r gathering the information.
vi ac reE. _-_ :3.7tions ofthe NCGO10000 General Permit and the approved Erosion and
and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
,e NCGO10000 General Permit,I will nonetheless ensure that all conditions of
re met on the project at all times.
-,-- Linder the NCGO10000 General Permit and understand that coverage under
this permit requirements for the discharge(s) and is enforceable in the
permit,
Name of Pro'ect:
Legally Responsible Organizational Entity: &A/,.GQ L t)
Legally Responsible Person:
Title of Legally Res po e Person: ;,�, _,,; c_
Signature: 'i Date: Z(�
"Print 'am Title of Si ut orized
Indi ' ual Differs from Permittee:
Phone Number: - �3`� '`[ t'1�4 e4
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
co,nstrucrion activity,such as a president secretary, treasurer, or vice president or a manager that is
authorized in accordance with Part IV,Section B, +'tem (6)of the NCG010000 permit.
For more information on signotory requirements, see Part IV,Section B, Item (6) of the NCGO10000 permit.