NCC203193_NOI Signed Certification_20200728

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, complete, scan mri unload to the electronic 1\10l.
Then, mail the original form to the NC. DEAALR Stol-rnQater Prograrn (with $10.0 check if paying ley check) at:
Divsion of Energy, Mineral & Land Resources Stormvdater Program
512 1\1, Salisbury Street, 6"' Flow (Office 64010
- 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
Pei, NC GeneralStotute 143-215.68 (i), oily person who kno"iingly makes oily false stotement, representation,
or certification in uny application, record, report, Dian, or other document filets or required to he mointoined
under this Article or o rule implementing this Article ... shall he guilty of .a Closs 7 misdemeanor which nlay
include a fine riot 'to exceed ten thousand dollars ($10,000).
Under penalty of law, 1 .certify that (cheep all bones to indicate your agreement):
I 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 du.e to violations of this
Permit.
Tile information submitted in this N01 is, to the best of my knowledge and Relief, 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 NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
It the approved Erosion and Sediment Control Plarl is not compliant with Part 11 (Stormvtlater 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 all times.
I ' I hereby request coverage under the NCG010000 General Permit and understand that coverage under
rids permit will constitute the permit for the discharge(s) and is enforceable in the
same manner as an individual pert -nit.
Name of Project:y L.Q �0
Legally Responsible organizational Entity: hIrR
Legally Responsible Person: Irian Wo u ' --
Title of Legally Responsible Person: ffi�(n+ _-
"Signature; r j - Gate; ` 3
`Print Name and Title of Signed if Authorized
IndividualOih'ers from Perniittee,
Phone NU11-1ber:_I /0 -_96G4 4-Ob -..
bKPOf 7-A NT NC' YE lhis�`ar1�� f��u i be signed la}r o respol siLle coda gate n frcel shot civdr�s nr ol�ercifes ille
C01V i1'uCt.lQ1T G`C1:111hj; SClCh aS C? 17rES10E17?.; secretory, tIL'L75rir-i'1; .t+!' Yl1Cc' 1-i7-t?SldLr7i; Qf (t lrranaae!' that IS
authorized in occordor7ce vid h Part it! Section B, Item (6) of the NCGO10000 pern7if.
For 1'116r'e rnforrr�.r.,tion on signatory rcrr�irernents, see pert iL:, �ctiofa r', It"� r,7 {'6j of the NCGt7?[0001�e1'1l)it.