NCC203328_NOI Signed Certification_20200812

NCG01 Notice of Intent (N I) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NISI_
Then, mail the original form to the NC DEMLR Stormwater Program (with $100 check if paying by check) at:
Division of Energy, Mineral & Land Resources Storrnwater Program
512 N_ Salisbw y Street. 6" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAI L THI5 FORM OR PAYMENT UNTIL YOUR OPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per IV General Statute 143-215.60 (i), any person who knowingly makes airy false statemer?t, representation,
or certification in ony oppltcotion, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include o fine not to exceed tern thousond dollars ($10,000).
Under alty of law, I certify that (check all boxes to indicate your agreement):
— 1 am the person Fespan si ble for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or crirninai penalties incurred due to violations of this
permit_
G�The information submitted in this NO is, to the hest of my knowledge and belief, true, accurate, and
cornplete based on my inquiry of the person or persons who manage the system, or those persons
erectly responsible for gathering the information.
will abide by all conditions of the NCGGO10000 General Permit and the approved Erosion and
Sediment Control Plan_
If the a pproved Erosion and Sediment Control Plan is not compliant with Part II (Storm water Po11ution
Prevention Plan) of the NCG030000 CieneraI Permit, I will nonetheless ensure that all conditions of
P rt II of the permit are met on the project at all times.
hereby request coverage under the NC 01e0Q0 General. Permit and understand that coverage under
this permit will constitute the permit requirements for tFie discharge(s) and is enforceable in the
same manner as an individual permit.
Narnc of Project:
Legally Responsible Organizational Entity_
Legally Responsible Person=
Title of Legally Responsible Person:
*Si nature: - - Date:
*Print {Dame d Title of Signed if Authorized
lodividua offers frpm Perrnittee: � ,��� � /� t
Phone Number; l `` r'
* IMPORTANT NOTE: This form mast be signed by o responsible corporate officer that owns or operates the
construction octiv+ty, such os a president, secretary, treosurer, or vice president, or a manager that is
authorized in accordance with Port IV, SecOon 6, Item (6) of the NCGO10000 permit.
For more information on signorory requirements, see part IV, Section B, ltern (6) of the NCG01C000 permit_