NCC203392_NOI Signed Certification_20200811

NCG01 Notice of intent (NOi) Certification Form
Directions:
Pont tr",Js iol' ; complete, scan alit upload Q the electro llc
Then.. rai: i, ihc i �; iz , : I )! rr'! tothe NC DEMLR Wnnwamr Pro onin (WIh 5100 LACk UPC..";111_? , b)f Check) at:
DIXon of Energy, i-O{IlGA 8' Lctllcl Resources StGrmwater Progran-i
412 N. sabbw y St e _, +_ ' FIcj,- {GMCF 6 :ul:? I
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
for Xc ani: ra C ou :� ..->c OU017,
or renown NMI Al : .� �, j � . , 1v rS rep or , plat), or other dCiCCl1?7e j&Ci or aqb + W ,.':'!ltf need
under this Ar ic;e Or O! L': o this ArOde , .. shall be ourif y+ ni a Coss ? 1i7hdoJir'000r +n- q� innyl
include aline I)of tO P_XC: - '­1 ors (5 0,Q( o)'
Under pent i:v of kv, , i LE.-.. , Azi , ., & A boxes to ;IILIWe yc]w ago C'm n):
[� I ani We pEson 1 ti. ,:. "Ar -ioi -iiz: cons-iruc on a hvitts of this pi'Qea or satisf'yirig he
re,llrements of As f3ermlt, and for any dvh or criminal pen aMes Inut rred due to OvIations of to
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The jlii-"mrtlo" sa Whop in As NOI t to the best of my krimyledge and heliet tri`,% 2ccu rate, a nd
cumpi ;_ AS& cii nn Qi.lAl of the person Or persons who n al-iFgc Lhe SystCii ' Cr hos4 Pel'sa is
directQ responsible too- gathering the information.
I Mil A;de by ad condi Ions of the NCG010000 General Permit ane the approved Erosion and
Seciinien Cui'6:roi Pli fn.
Me` Nine aFij✓fww ci' dah and Sci: hvent Contial Pin Is not tilt plicnt bv1Lli I:iiai € II {-N-cor-livvai*]c P'LAI.Aioll
PmveiAinn Hat of We NCG010000 General Permit, I Ki nonetheless ensues that ali conciitlons of
Part li of the permit are met on the projecL �t all timiies.
SA i hereby request coverage timer the NCGO10000 General Permit and undeisi-anti that coverage under
this pen"A 'i'. d cA71'lsi uke WE pel'nllt requiremenas for ihL �ESCi'icl' c{s.l and is ent "-)rcu bki in l.hc
san'iz Illy I1riEr `c= 2n li"i61+iGl.ldl pEfil"`It.
Name of Proj.t�c'i: _oFA Hyty /%J D r�'?-�c�echOn _--- 0n e � 'hTwo Aot ,1S9
Lenally+Respnn�ihle t)rni%a`:ional Entt=ti+: -� clCin*�_�nm p(j� Rut('_v1 I',
Lei:ally Resr'onsibY Amon:
Title of Wgal" Resperilsii;lc= Person:
'`'Pfho 1� me and' -._I Crl wirneo it ,),,WThea
(rl�i,ln.� _. �+ i1 0� „- i�.,, r ii-ir'f,ti,:i r•. il'F17'i fiPl11I .�+Y ., i -,
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