NCC203029_NOI Signed Certification_20200717

` . Notice of intent (N0Q Certiffication 'Form
t lC). s
Print this.form,complete,scan and upload to the electronic NOL �!
Tbq",:Mai1 the 0 f i oal forM tc the DEWR StonnVsfe t+?r Program t3 t c t$t with"` � Et�C G'tf fJ£7�!i 9 y check), t
!) siob of Etcet r,Mi er l& 1arrd l��svurces St rmwater Proust
SIZ WSatisbury Street} 61'Roor'Gff'ilce 540K}
1 1 flail Service Center
Raleigh,K 27699-1612
DO NOT MAIL THIS,FORM OR PAYMENTTJL YOUR APPLICATION HAS BEEN
REVIIEWEDAND`ACCEPTED AS,COMPLETE
Per. NC Generaf.astute 143 215A9 any person who know4ggly makes airy false statement
or c rt jficaVo�i sra any application, reciaro,repoft,pion, or other€focumeatfiled or requioed to, e Fr g!htdioed
under this Article or a role(M. Ple.r eating this Ark'cle_ : sh,0 be guilty of o,Class:2 mis. eme..000r which may
incfude o fine ewt taMeed tear 2heacrscr X dO(fars($W,400).
Under pefiatty of law,i tertifV that�cjjer-k all bog-5 to'indicate your agreement),-
1 am the Person r spo"S1.We for the constrw:tion activities of this pro) ct,for satisfying the
regvire eMs ofthis.Per tit,and for arty clv l or criminal penakti s imarred dui t�viral tiorr�c��t�ais
p8rMit.
10 The information submitted in this € of i5. to the best ofmy kriqwl�dge and Ja l ef,true accurate,and
o7mpietk-teased Of,my inquirer of t o pemon or Persons Wbo m r age the�iysteam, or thosa person
sdir�ctiy ri�spposiW e for gatheriiig.the infurtxiatlovt
.1 I will 4ide icy' ff conditions of thl` V� grid th-e ap(33 ve4 ErDs1(.TT1 aC3o
Sediment Controf Plans.
:t'the appmVed Erosi:on and 5 diment'Ccnuo #'fan is not.CC�I?'1pljant with P�art It(StorrrB.water Poll€atle.n
Prevention Plat)of the �d� ensure'that d13 c0 d ticaris of
Dart ii.of the permit are.s�et ovi the omilact at ali times.
i heroy request crag'ef8 e tinder-the i�����1� Cr�e e a ��.r�;a�anj understand that Coverage rmder
tills.permit gilt constitute the permit requis emenfs.for.tha discharge(s) ai d is enforc&We!in the
same roann2i'a ao individual perrom
4 ,
Name of l?tiia:t -S. .: ' .
lregafy R esponsible orgaoizational Entity: i i vz r ►nn
galty fte r sil i Pe szin; r Q ;>�
title;of tkpily:ReS.cOMble P&soa,
l atv:
*Mai Name and Tt le(af Signed i ' hnrized
Phone ( diti{� r:: ► ` _ 4--
*:IAVOR'TANT?1 OTV� th s farm must be.5 gned by a resiaoosikfe corporate afficer thq e tas of operates the
t`e�t?strt�cf'r€ari a�l-list�r, src�..��presi�lerit,secr�trsr�r; :reasr�rer, �i-rice�resiclerit �r rr trrir� ex ghat is
0000fized in uc.carr ome With-part iv,section B,ftem.;s)Of the NCG010000permi
For mare information on signatory requirements, see Porn lV,.Sectiun 6, item(6j of the MG010006 permit.