NCC203568_NOI Signed Certification_20200818

NCG01 Notice of Intent (NOI) Certification Form
Directions:
Print this form, cornplete, s.cari and upload to the electronic, N01.
Then, titan the original form to the NC D1 MI-R Sto.rmwater Program (with $100 check if poyin(by check) at:
Division of Energy, Mineral 9 Land Resources Stortnwater Program
512 N. Salisbury Street, 0 Floor (Office WK)
16J.2 Mail Service Center
REi e60, NC 27699-161.2
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per IVC.General Statute 143-115.GB (i.), any person who knowiogly slakes any false stottnv)iL, representation,
ar r_ertificatiori in aa7y aPplicotion, record, report, 13lc71), Of-othC1- doCUMent filed rn" required to be moiniained
under- this Article or u rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine sot to exceed ten thousand donors ($10,000).
Under penalty of lavtl, I certify that (check all boxes to indicate your- agreement):
1 am the person responsil:,le for the construction activities of this project, for satisfying the
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
coniple-re 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.
if the approved Erosion and Sediment Control Plan is not compliant with Part II (Storm'water Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part i1 o`the permit are met on the project at all times.
I hereby request coverage under the NCGO10000 General Permit and understand that coverage under
-this permit will constitute the pern"tit regcrirements for the discharge(s) and is enforceable in i:he
same manner as an individual permit.
Nar7`re of Project: TV-%-e M 0,n CWJ Q.f n P I a-n ct�h_0 ki P&V gC —
Legally Responsible Organizational Entity: (ar& r-"' c o; ap `7 y
Legally Responsible Person: Drior) walk
Title of Legally Responsible Person; M+
*Signature: Jntx� Tate: 2-02-0
`Print Name and Title of Signed if Acrthori?ed
111dividual Differs frOr71 Pt'1`Iliitt�'e:
Phone Nluniber: 1I U 966-14MA,
11'irN,V, TANT N('_1T 1_=: 1 his fora? must be signed by a responsible corpDrate officer, that ov�rrls or operates the
cnr1:'irr rtinr7 1c tii�i '); Such os c 1?reskrerti; set: fry, treasurer; rr vice /.-r-r_-sir,'e,1t; or t�r r71n17ager itl7ai is
authorized in occcv'danr=e r,rith (mart W, Section B, Iren7 (6) of the NCG0100001jer177it.
1-Or n-jore inform otion On-signotory req,,uif cLja P01"t IV, SeCiiOO R, 1Yei i9 (6) Of 010 r'1IC'G-1_1(10001)er irt,.