NCC203178_NOI Signed Certification_20200728

NCG01 Notice of Intent (NQI) Certification Form
Directions:
Print this 'form, complete, scan acid upload to the: electronic: i101.
Then, mail the original forrn to the NIC UEMI_R Sto.rmwater Program (with $100 checl< if pa)ling bycheck) at:
Division of Energy, Mineral & Land Resources Stormvvater Program
512 N. SalisbUry. Street, 6`r' Floor (Office 640K)
1612 Mail Service Center
Raleigh, h!C 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per NC General Statute 143-215,6B (i), anyl.7ersQr7 01110 1070 riOgfy laaakes any false stotement, representation,
or certification in ally application, record, report; pfull, or ether doct. ment filed or required to be uluilltairaed
under this Article or a rule implementing this Article ... shall he guilty of a Class 2 olisdenlearnor Which may
include a fine not° io exceed tern thousand dollars ($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 or criminal penalties incurred due to violations of this
permit.
iye The information submitted in this NOI is, to the best 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 infor rnation.
N" I will abide by all conditions ofthe NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Frnsion and Sediment Control Plan is not compiiant with fart 11 (Stormwater Polll.ition
Prevention Plan) of the NCGO10000 General Permit i will nonetheless ensure that all conditions of
Part II ofthe permit are met on the project at all times.
54, 1 hereby request coverage onder the NCG010000 General Permit and understand that coverage under
this permit. will constitute the permit requirements for the disch-,irge(s) and is enforceabie in the
same r-rianner as an individual pen-riit.
Name of Projec'i; V UD
Legally Responsible Organizational Eiitity: t� - Gz-h &m 0-� ea-k,oA ale
Legally Responsible Person: Prio'n Wilke'
Title of Legally Responsible Person: NLC<-n+.
'Signature: {/1.�,�,J�� _ Ciate:-
"Print Name and Tittle oi-Signed ifAutl7orized l r
Individual Differs fron? Pernnittee,
Pl-lone Number: 1a - "4 6G-ff alp _ ---
Ifir[r0rf/j,1 11 1tiraiu' this fnrrna 1)au; he signed by a responsible corporate officer that oluns or operates the
r0i.f fr oc.tioo uci;illlt')> such cis a preyidell , secrC-tggll treosul-er, or vice president, or o n7anoge.r glut is
authorized ill oceordonce with Pal{ A/, 5ec11011 B, itEM (6) Qf MC WG010000 perrnft
err 17iore in ornlution On signctory reo rrire:mf r7ts, see Pcrt Il! der:'.+C,rr B, item (6) of the NC'rOl.C?000perr iv.