NCC203575_NOI Signed Certification_20200818

NCGO1 Notice of Intent (NOI) Certification Form
Directions:
Print this iorrn, complete, scan and upload to the electronic N101.
Then, mail the original farm to the NC DEI\ILR Stormwater Program (with $.100 check if paying by check) at:
Division of Fnergy, Mineral & Land Resources Stormwater Program
512 N, Salishury Street, 6'�' Floor (Office 640K)
1612 Flail Service Center
Raleigh; NC 27699-1612
DO NOT MAIL'rH1S FORM OR PAYMENT UNTIL YOUR APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per lVC General Statute 143-215.63 (i), ony.person who knovilingly makes uny false stutement, representation,
or certification in a17y oppli.cation, record, report, plan, or other- documeni jfled or required to be t7lointuined
under this Article or a rule implementing this Article ... shall be guilty of a Clus.s 7. mh demeanor v,11 ich may
iliclude a fine not to exceed tell thousand dollars ($10,000).
t}ndel• penalty of laud, I certify that (.check all boxes to indicate your agreement):
i am the person responsible for the construction activities of this project, for satisfying the
requirements afthis permit, and for any civil or criminal penalties incurred due to violations of this
Ile�it'
l-he information submitted in this N01 is, to the best of icy knowledge and relief, trite, accurate, and
complete based on my inquiry of the person -or persons who manage t-he system, or those persons
directly responsible for gathering the information.
IN, I w1ll abide by all conditions. of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
'u� If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stcrmwate.r PCHUtion
Prevention Plan) of the NCG010000 General Permit, I vvill nonetheless ensure that ail conditions of
Part II of the permit are met on the project: at all tines.
I hereby request coverage under the NCG010000 General Permit and understand that coverage under
this pef-mit wi11 constitute the permit requirements for the discharge(s) and is enforceable in the
same iaaanner as an inciividv.al permit.
Name of Project: And"Ann nrc,*IC (.N Nina. Phuae 8 Ste+ion 2B -,1&I7 qcl-101 6� 103 -
Legally Responsible Organizational Entity: H �
Legally Responsible Person: C 0 r) WilklIC&r_.
Title of Legally Responsible Person: ft�_M+
'���
"Signature:Gate• - r'j 1
*Print Name and i itle of Signed 1) Authorized
Individuol Differs1ron—, Permittee:
Phone 1\iim-:ber:
fMIT(J('7AhT NO7E- This forii7 must be .signed by a resp017S ale Col porn 1.e c,17,.c,,. thot• ov"lls nr operates the
y sf?Ch as o 13rEsrr?er}t; secYe-tary, treasurer, .Ur' 1-ice presri r17t, Gr- (1 M01?ager that is
t,U�i_0 i'.'-"('-_:J;. ice ti,rlth Part Ai Section ii, item (5) pf -che hrCG010000l_­o-nii.
For more i;,r' rl-aulUon 0r7 signatory see Pori ll; 5ectinn B, itrrni (6) _i`hc AICG910000perrnit.
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