NCC203146_NOI Signed Certification_20200724

NCGO1 Notice of Intent (NQi) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic K101.
I hen, nail the original farm to the NC DEMR Stormwa'ter Program (wish $100 check if paying by check) at:
Division of Energy, Mineral & 1-and Resources Stormwater Progran7
512 N. Salisbury Street, 0 Floor (Office 640K)
1S12 Mail Service Centei-
Raleigh, NC 27699-1512
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per IVC General Statute .143-2.15.68 (i), uny person u'ho lmowirlcgly molces uny false stater.77ent, repre.sentcrtion,
or certificatior7 is any application, record, report, Plan, Or other document filed or req, aired to be maintained
under this Article or a rule implementing this Article , .. shall be guilty of a Class 2 misdeineanor which may
include a fine not.to exceed ten thousand do.11ors ($10;000).
Under penalty 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 ol- criminal pen aities incurred due to violations of this
p e run it.
5/1 1-he information submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and
complete based on nay inquiry or` 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 NCGO10000 General Permit arid the approved Erosion and
Sediment Control Plan.
if the approved Erosion and Sediment Control Plan is not compliant with Cart Il (Storm water Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at aA times.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under
phis permit will constitute the permit regUil ements for the discharge(s) and is enforceable in the
sarne nianner as an individual permit.
Larne of Project: PanjDmf,Ph ie 2A ao h 1-1
Legally Responsible Organizational Entity: H � fl Co
Legally Responsible Person- OfiN q Wlkkec-
Title of Legally Responsible Person; �-q�
*Signature: �,�1�h. �k Date; 7 f qo ' o
*.print Name and Title of Signed if Authorized
117dividuol Differs from Permittee:
i�►�tor3c I���rml�e�: �! d` �`t��_.L.���ta��' ---- ---- _---
/A1rJ(;R7AA1TTv/07E; 1h1.5form 177UA be Sig rird by a r-esponsibie Corp 01-,te officer- Mat ovens 01- operazF the
Con-'tfurt1011 uctiv t)� Such Os Q pj- Sicient, secreior'y, treorsurer; or vJce 1_-wesiLlcyi , or o rnpnopci .thot-is
oufhorize:d in occordnr7ce with Part I1; Sect'ior7 Q, it�e77 ([� of .rl7e 1VCG010000 perrr7it.
For -pore !Oforrout!on on sicrr7r)ro1'y see Part h ; feciion P., Ifeto (6) of the NCG010000permir.