NCC202960_NOI Signed Certification_20200714

NC 01 Notice of Intent (N01) Certification Form
Directions:
Print this form,OWVliee.scan aMd upload to the electron lc 1401,
-Tben.m:a II tho or*kW form to the NC OElVliA Stormwal&r brag rarer(wlth$100 check if paying bV checkl at-
Olwision of Energy,h4pneril&Land Resources Storrnwster Program
511 N_5ahsbuw~,+Street,61'Floor(Office 640KI
1622 Mail ServrceCenter
Raleigh,NC 27699.1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General$towr]+w3-CIS- (i),onyqer5on whop krK'4''ngP y meeker any Jake statement.represenrarxarr.
or€ertrficorw in any apo radon,rerarrQ,repar-t,plarF,or otlyer dorumenr frhd or required to be mWaitu wd
Under Ihd Arh0v or a ruit irnplCmCn ting this Article.,,Shoff be gw ty of a irlasf 2 miS meaner which 1"Icy
+rmhode a fine not to eareed tern rhouumd dodoes
Meader penalty of Isw.I certify that(duck all boxes to indicate your sgreenwrit):
I I am the person msPQn s+bte for the corns#uction acth+i I io of this P roject.for satisfying t he
requirements of this perrnk and For any c►ni or cnmlrwl Pena liras incurred due to violations of th Is
permit-
Tb#rrlfoimatrnn submitted i*this No I is,to the best of my kniotirlecge and belief.tri.re,accurate, ar4
corn plete ba sed on myr i n4uiryr of the person or persons who mana$,e the system,or those pe•r5ons
dinectFyr respon PtWe For galtwrrng the trrfonTwitron_
I will aWv by all condliiorrs of the NCG010MGengraI Peru,and the aDProVrd Erosion and
Sed if%W Controt Pla A.
1 1 If the approved Erosion and sediment Control Plan is rot compliant with Part II MLOMwater Pollution
Preverition P4anl of the NCOIM Gerwal PumiL I will nonetheless ensure that a0 canditronsof
Po r#as of the permit are met on the protea at all tlmon.
I hereby requrtst coverage undrtr the KGQjQM i-renerak Fermi an4 understand that camrage gInder
_ this permit will constitute the permit rin;LOernents for the dlscharWsl and is-enforceabie in the
same mAnner as an i adividual permit
Marna of Fiolect. PNG Bryson Park Qdens*on
tepityP.eWnsib eOrganizatiertalEntrty- Pledmnt Natural Gas Company, Ind
Lepily lkeswnsibe Person: Kevin $ell
Title of Lepily Re Bible Person'QoeMfiQfts Ma ruaqer
•51 attire: ate; '/ram
*Print Narnxe and Title of Signed if Authorized
individual i rs fram Perariltee:
Phone Number- 336.726.7763 '—
' IMPORTANT NRTF_ r of fofm must b+e stgnrd by o nmpmsrble roepi gate officer that owns or open tes the
e wrs t ruction xtivity,such as a president,wrferdry,rrrafure,cw vice p�rrsideeti or a manager that is
uuthw and in occwda -r with Part W.Sactmm 9,Rem(6)of th#NC601l permit_
For mww fnfomwtion ore signafory mVui`rrnvnM see Part W,Section 8,Item(6)of the ArC60iDWoperrnif.