NCC202950_NOI Signed Certification_20200714

NCG01 Notice of Intent (NCI) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NO].
Then,mail the original form to the NC QEMLR Stormwater Program (with$100 check if paying by check)at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.5aItsbury Street,6- Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215.6E(i), any person who knowingly makes any false statement,representation,
or certification in any application, record,report plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article. . .shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars($I0,000].
Under natty of law, I certify that(check all boxes to indicate your agreement):
I am the person responsible for the construction activities of this project,for satisfying the
requirements of this permit,and for any civil or criminal penalties incurred due to violations of this
permit.
the information submitted in this NO is,to the hest of my knowledge and belief,true,accurate,and
complete based on my inquiry of the person or persons who manage the system,or those persons
directly responsible for gathering the information.
I will abide by all conditions of the �7C01 0000 General Permit and the approved Erosion and
Sediment Control Plan.
f71 If the approved Erosion and Sediment Control Plan is not compliant with Part ii(Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit, I wick nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I hereby request coverage under the N GO10000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharges)and is enforceable in the
same manner as an individual permit.
Name of Project: LEA It-1L CC 1 2,1—C
Legally Responsible Organizational Entity: ) ,rL,Ir✓ >R C� z2,G
Legally Responsible Person: f L
Title of II erson:
Pint Name and Title of Signe r Authorized
Individual Differs from Permittee:
Phone Number: 71) q Al�— Q,3315-
*IMPORTANT NOTE: 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
authorized in occordance with Part IV,Section B,Item(61 of the NCGO10000 permit.
For more information on signatory requirements,see Part 1V,Section B,item(6)of the NCGO10000 permit.