NCC203361_NOI Signed Certification_20200811

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Directions:
Print this form, complete, scan and upload to the electronic NOI.
Then, snail the original form to the NC DEIVI_R Stormvdater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Stormvdater Program
512 N. Salisbury Sti-eet, 6"' Floor (Office 64010
1612 Nflail Service Center
Raleigh, NC 27699-1612
-)0 NOT MAIL THIS M OR PAYMENT APPLICATION
tEVIEWED AND ACCEPTED
Per NC General Statute 143-215.6E (i), any person who knov,4ngly makes any false statement, representation,
or certification ht any application, record, report, plan, or other document filed or required to he maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of laud, I certify that (check all boxes to indicate your agreement):
Ike I am the person responsible for the construction activities of this project, for satisfying Che
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
—° permit.
The information submitted in this NOI is, to the best of my knowledge and belief, true, accurate, and
complete Lased on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering -the information.
L I vdill abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwate- Polluilon
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,
s I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this permit will constitute the permit requirements for the discharges) and is enforceable in the
same manner as an individual permit.
Name of Project: l 0
Legally Responsible Organizational Entity:
Legally Responsible Person:1(�4
Title of Legally Responsible Person: {
:Signature: 1 _ Date: + 2-1- 2-0 0.
"Prini Name and Title of Signed if Authorized
h)diVidUal Differs from Pemittee: W f
Phone Number: 1-16 ef tX11-1'_
1AV)0 1' N7 N07L:"; 1 his form ntcrst be signed by a responsible corporate officer ih0t 011ims or operates the
construction oaivity, such as a president; secretor'y, treasz?rer", or vice president, or a manager' thou is
authorized in occordoncc vlith Pur't f1 Section G, Item (b) of the IV( G0100001)eattit,
f-or n'tore inforrnrrtion on signoiory requirements, see Pori 11 feciiorr 13, ite,°;t (6) of the NCG010000 permit.