NCC203515_NOI Signed Certification_20200817

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
PrOt thl iorii complete, scan 4,nd upload to the electronic 1'%10!.
ilea, mad the orig€nal form to We WC DEMLR Storlawater Program (with $3-00 check if paying by check) at:
Division of Energy, Wrieral & Lana Resources Storn-nlvater Frograrn
J 512 IN, Sal imi-y Street, 6"" Floor (Office 640K
169.2 Nail Service Center
Raleigh, IIC 27699-1612
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per W Genera! Sratu'te 143-215, bB (i), ony person who knowingly makes arty false sta'ement, representation,
OrCertlfOUNDn 0 aflyCfJlJiiCa6lCl; reCord' 1-c—pori, P1017, 01-Other docuo-,ems ikd or required to be nicintaineQ
t117Rer this Article Or a rule rniplen-,enting this Article ... shall be guilty o1 a Class 7 lnis erneonor -,,vhich may
include a fine nor to eYCped ten thousand dollars ($10,000).
Under penEhy of law, i ce:-tity that (check all boxes to hdOme yow agmemem):
1 aril tie pErson responsible for the ConstruVon activities of mils project, for sai.iS 'ong the
regLdrements of Ws permit, and for any All or criminal pen2lties incurred erred duE to violations of this
peniik
Ile Aformation sulimtied in this I\01 is, to he best of icy knowledge and belie? tTL'.e, accurate, ally'
complatE ; amd sn my Cf the person or persons who i-n anagc the syAem, or those persons
directly responsible for gathering the information.
r i if K al}iQe by ad condMons of the N ICG010000 General Permit and the approved Eroslon and
Sediment Control Plan.
11 , If the appoo'ved Criidon and Sedhoani WWI Pin is not corFliJhant 5+lrl h Pain H Qmmanor Pollution
PrGveiltion I'WQ of the NCGO10000 General Permit, I will nonetheless ensure that all conaitians of
Part ll of the permit are met on th-:= project at all times.
N i her -ley request coverage Wer the NCGO10000 General Permit and understand that coverage under
this pern-J.." 14111 constitute tilt permit, requirements for the diisCi`argeisf and IS enforceable in the
same nannu as an ii1t:{ivAM permit,
Name -of Frojeri:_ VD Q0 0 0 Ql II (�`` - - � _----
LegallyResronsil.de Organkational EntRy: H t. i�. [. jr-i5�-)1`u .�}� A��it��?S��C
-Legalk/ Responsible Person:--- )n&r)b0how -- ------------- -- -----
Title of Lcgally RnsponsNe- Person: -l-Aw+-
1 3 U20
OVA Name and i HN o? Sped f2 .'`.uMoNed
iriLril�li'ii�?l Lori%pis >;•(7r1i ;-Er"ir''�:�r:
P,loric i tfllli�e : `T/ 0 -- (.f
M1'[ %l;1:.,°,'`i „ -..._. .. -- _ .... n - .: l to s'_ ;e d by a , npms0e L f.`. v l i,, . _ . .., tv spervas We
ifr i:(; N ok r no,, n G! SI f r.", it iten; a, of imp =;jj'i 000 pa lr' 4.
f �1r .....�;._ ..e _ Son:._. ...am S`r._�-see a h ACO .. f, r�C h